Cognitive rehabilitation after acquired brain injury: knowledge, attitudes, and practices of healthcare professionals in Lebanon

Abstract

Background

Acquired brain injuries (ABI) cause cognitive impairments that significantly affect occupational performance and quality of life. Despite their prevalence in the Middle East, ABIs are underexplored in Lebanon, particularly in terms of cognitive assessment and rehabilitation. This study provides the first insights from Lebanon and the Arab region into Lebanese healthcare professionals’ knowledge, attitudes, and practices (KAP) regarding cognitive impairments following ABI.

Methods

A cross-sectional study was conducted in Lebanon between January and April 2025 using a self-administered online questionnaire assessing KAP. The sample included 61 healthcare professionals actively working with adults with ABI.

Results

Participants demonstrated an overall level of knowledge (mean score: 72.76%). Attitudes were favorable toward continuing education, cultural adaptation of assessment tools, and combining standardized and non-standardized methods. Key barriers included limited specialized training, absence of locally validated tools, and insufficient context-adapted resources.

Conclusion

Professional practices align with international recommendations; however, gaps remain in training and the availability of context-specific resources. These findings highlight the need for targeted training, culturally adapted tools, and structured clinical guidance to improve practice and inform policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09438-7.

Background

An acquired brain injury (ABI) refers to brain damage that occurs after birth, whether traumatic or non-traumatic in origin [4, 18]. Traumatic brain injury (TBI) results from an external mechanical force, whereas non-traumatic brain injury (NBI) is caused by an internal pathological process that alters brain tissues [7, 9]. Common causes include road traffic accidents, falls, sports-related injuries, and acts of violence while NBI can result from stroke, tumor, infection, or anoxic events [7, 9, 29, 33]. Regardless of etiology, ABI leads to physical, sensory, psychological, and cognitive dysfunctions [10, 11].

Cognitive impairments following ABI commonly affect memory, attention, and concentration, and are often associated with reduced self-awareness, which can hinder adherence to rehabilitation [12, 32, 35, 37]. These deficits significantly impact activities of daily living, occupational performance, and return to work, underscoring the essential role of cognitive functioning in maintaining independence [5, 17].

Rehabilitation is a key component of care, and typically involves an interdisciplinary approach [2, 11, 31, 38]. Evidence suggests that interventions such as metacognitive training, multimodal therapy, and computerized programs can improve functional outcomes [16, 23, 39]. However, despite these advances, uncertainties remain regarding the most effective approaches, particularly in low-resource and culturally diverse settings. There is limited evidence on how cognitive rehabilitation is implemented in clinical practice, especially in Lebanon. Furthermore, the lack of nationally representative epidemiological data on the incidence and prevalence of ABI in Lebanon limits the ability to estimate its national burden. This gap highlights the importance of studies exploring current clinical practices and professional perspectives.

In the Arab region, including Lebanon, there is a significant lack of published studies examining cognitive assessments and rehabilitation practices for individuals living with ABI. In particular, there is limited evidence on how healthcare professionals apply evidence-based approaches, adapt tools to local cultural and clinical contexts, and manage cognitive impairments in everyday practice. This gap limits the development of contextually relevant interventions and training programs. Assessing healthcare professionals’ knowledge, attitudes, and practices (KAP) is therefore essential to identify existing gaps, inform training needs, and support the development of contextually relevant rehabilitation strategies [1, 19].

This study aims to address this gap by conducting a KAP survey among Lebanese healthcare professionals. Specifically, It seeks to (1) evaluate professionals’ level of knowledge regarding ABI and cognitive rehabilitation with particular attention to assessment and evidence-based approaches; (2) explore professionals’ attitudes toward cognitive assessment and intervention, including perspectives on standardized tools, multidisciplinary collaboration and technology use; and (3) examine current clinical practices and contextual constraints, with a focus on the use of assessment tools, intervention strategies, and perceived barriers to effective cognitive rehabilitation in Lebanon.

Methods

Study design and participants

This is a cross-sectional study conducted in Lebanon between January and April 2025. Participants were recruited using a purposive sampling method targeting licensed healthcare professionals actively involved in adult ABI rehabilitation. The study involved occupational therapists, speech therapists, and psychologists. Participants were required to be involved in the assessment or management of adults with ABI, with no minimum caseload threshold and no restrictions regarding work setting. Neuropsychologists were not directly targeted, as neuropsychology is not established as a distinct clinical discipline in Lebanon. A minimum of six months of professional experience was required to ensure an adequate level of clinical exposure and familiarity with ABI-related rehabilitation practices.

Instrumentation

The questionnaire used in this survey was developed by the authors, based on an extensive review of scientific literature on ABI and associated cognitive impairments [18, 38]. This review identified key areas of knowledge, common attitudes, and current clinical practices. The questionnaire is available in English and French, which are the primary languages of instruction in healthcare education in Lebanon, and participants were therefore expected to be proficient in at least one of these languages. The language of administration was not systematically recorded. To avoid missing data, all questions were required to be completed before the final submission. The full questionnaire is provided as an additional file.

The first version of the questionnaire was revised based on feedback from two experts: a professor specialized in the research field and a clinical neuropsychologist, both with more than ten years of experience. Their feedback was instrumental in refining the wording of the questions and ensuring clarity and relevance. An independent committee of eight experts specializing in the management of cognitive disorders in people with ABI evaluated the questionnaire content. The review process was guided by a structured approach aimed at achieving expert consensus through iterative feedback, although it did not follow a formal Delphi method [34].

Although only one round of expert review was conducted, the structured feedback significantly contributed to the content validity of the questionnaire, ensuring clarity, relevance, and coverage of the proposed items. The evaluation was carried out using a structured questionnaire focusing on clarity, relevance, and coverage. After incorporating expert feedback, a final preliminary version of the questionnaire was developed.

The online questionnaire consisted of 66 questions divided into four main sections:

1. Demographic Information: The sociodemographic profile of the respondents was established through 12 questions concerning demographic characteristics such as age, sex, years of experience, and level of education as well as therapeutic background, work setting, along with closed ended questions about their clinical practice and case load.

2. Knowledge: The knowledge assessment covered key aspects of ABI and associated cognitive impairments. This section consisted of 16 single-choice questions, with only one correct answer. Correct answers are scored 2 points and incorrect answers 0 points, with a total score ranging from 0 to 32. Higher scores indicated greater knowledge of ABI and cognitive rehabilitation principles.

3. Attitudes: Exploration of professionals’ perceptions and beliefs regarding the importance of early assessment and intervention, as well as the use of various assessment and intervention tools and methods. This section included 18 statements assessed using a 3-point Likert scale (“agree,” “neither agree nor disagree,” “disagree”), with a total score ranging from 0 to 54. Higher scores indicated more favorable attitudes toward evidence-based cognitive rehabilitation.

4. Practices: Exploration of current practices of professionals regarding the assessment and intervention of cognitive disorders, as well as their needs for continuing education and innovative technologies. This section included 19 questions combining closed-ended, open-ended, and frequency-based formats to allow for an in-depth analysis of current practices. Aspects addressed included the cognitive functions assessed, the perceived effectiveness of interventions, the challenges encountered, and the specific obstacles related to cognitive rehabilitation in Lebanon.

Pilot testing

A pre-test was conducted with eight Lebanese professionals experienced in cognitive rehabilitation to check the clarity and comprehension of the questionnaire. Based on their feedback, the questionnaire was revised accordingly. The average time to complete the questionnaire was 25 min.

Data collection

Healthcare professionals were contacted via email announcements distributed through official stakeholder platforms such as the Lebanese Union of Occupational Therapists, the Lebanese Association of Speech Therapists, the Lebanese Psychology Association, and the Higher Institute of Speech Therapy at Saint Joseph University. A follow-up email was sent three weeks later to encourage participation. Social media channels were also used to disseminate the survey, which was hosted online via Microsoft Forms.

The invitation letter explained the study objectives and emphasized voluntary participation. Respondents were informed that completion of the survey implied consent to participate. The questionnaire link was distributed to an estimated pool of over 500 Lebanese healthcare professionals. A total of 136 people accessed the questionnaire, of whom 48 declined to participate, and 25 withdrew before completion. The final sample comprised 61 participants. However, as the exact number of professionals actively working with adults with ABI in Lebanon is unknown due to the absence of a national registry, a response rate could not be calculated.

Ethical considerations

The study was approved by the Institutional Ethics Committee of Saint Joseph University of Beirut (USJ-2024-33). Participation was voluntary, and all respondents were informed of the objectives of the study and provided informed consent. All procedures were conducted in accordance with the principles of the Declaration of Helsinki [40].The survey was conducted anonymously to ensure the confidentiality of participants’ responses.

Data analysis

Statistical analyses were performed using IBM SPSS (Statistical Package for the Social Sciences), version 22.0. Descriptive statistics were used to summarize the data, including means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Some variables were grouped for analysis. Differences in knowledge scores between professional groups (occupational therapists, speech therapists, and psychologists) were examined using one-way analysis of variance (ANOVA). Associations between knowledge scores and clinical experience variables were examined using Spearman’s rank correlation coefficient, given the ordinal nature of these variables. Associations between categorical variables were analyzed using the Chi-square test. Qualitative responses to open-ended questions were analyzed manually using a thematic categorization approach. The level of statistical significance was set at p < 0.05.

Results

Characteristics of the study respondents

A total of 61 respondents completed the questionnaire. Table 1 presents the sociodemographic and professional characteristics of the sample. Participants were predominantly female and relatively young, with a mean age of 29.66 ± 6.35 years. Occupational therapists represented the largest professional group, followed by speech therapists and psychologists. Most participants held at least a bachelor’s or master’s degree and were primarily based in Beirut and Mount Lebanon.

Table 1.

Characteristics of health professionals participating in the study (N = 61)

	n	%
Sex
Man	9	14.75
Women	52	85.25
Age (in years)
20–25	21	34.43
26–30	19	31.15
31–35	8	13.11
> 35	13	21.31
Mean ± SD:	29.66 ± 6.35 years
Occupation
Psychologist	12	19.67
Occupational Therapist	35	57.38
Speech therapist	14	22.95
Highest level of education
Bachelor’s degree	28	45.9
Master’s degree	29	47.54
PhD	4	6.56
Caseload with population having ABI
0–25%	34	55.74
26–50%	18	29.51
51–75%	8	13.11
> 75%	1	1.64
Cognitive rehabilitation caseload
0–25%	25	41.0
26–50%	23	37.7
51–75%	10	16.4
> 75%	3	4.9

In terms of professional experience, most participants (65.6%) had more than 4 years of clinical experience; however, specific experiences with people with ABI varied across respondents. Regarding specific experience in cognitive rehabilitation, the majority of participants (52.5%) had between one and three years of experience.

Participants worked across diverse settings including rehabilitation centers, and private practice. With respect to clinical workload, the majority of respondents reported devoting less than 50% of their time to the ABI population (85.25%) and to cognitive rehabilitation (78.7%). In contrast, only a small proportion (4.9%) of participants reported devoting more than 75% of their workload to cognitive rehabilitation.

Professionals’ knowledge of ABI and cognitive dysfunction

Overall, as shown in Table 2, participants demonstrated an overall level of knowledge, with correct responses rate of 72.76%, although some gaps were identified, particularly in cognitive assessment and evidence-based approaches. Knowledge was stronger in domains related to general ABI concepts and rehabilitation strategies, with high recognition of key elements such as ABI definition and common causes. The second domain concerning cognitive impairment following ABI, most respondents were able to identify fundamental concepts about cognitive impairment (75.41%). In contrast, lower performance was observed in more specific areas, particularly working memory, with a correct answer response rate of 55.74%, and cognitive assessment, which had the lowest rate (63.93%). Assessment tools remained more limited. While the objectives of cognitive assessment were generally understood (72.13%), familiarity with specific assessment tools was limited. Overall, participants showed better knowledge of rehabilitation strategies (77.05%), although understanding of evidence-based approaches remained comparatively lower (57.38%). This overall average suggests that professionals have a consistent level of knowledge, with some gaps observed in specific domains.

Table 2.

Level of knowledge of health professionals

Domain	Statement evaluated	Correct Answers		Incorrect answers		Average of correct answer by domain
		n	%	n	%
Acquired brain injury	Definition of an ABI	54	88.52	7	11.48	79.91
	Stroke can lead to ABI	57	93.44	4	6.56
	Hypoxic-ischemic injury is a common cause of cognitive deficits	43	70.49	18	29.51
	Brain infections/inflammations can cause ABI	41	67.21	19	31.15
Cognitive Impairment After ABI	False Claims About Cognitive Disorders	46	75.41	15	24.59	70,164
	Brain area linked to visuospatial deficits	47	77.05	14	22.95
	Working memory in cognitive processing after ABI	34	55.74	27	44.26
	Type of memory most commonly affected in adults after ABI	44	72.13	17	27.87
	The importance of attentional control in cognitive functions	43	70.49	18	29.51
Assessment of cognitive disorders	Main objective of a comprehensive assessment for patients with ABI	44	72.13	17	27.87	63.93
	Cognitive assessment tool frequently used in rehabilitation	37	60.66	24	39.34
	Assessment tool for measuring functional cognition	36	59.02	25	40.98
Intervention and rehabilitation strategies	Most effective strategy to improve memory and executive functions	51	83.61	10	16.39	77.05
	The “Use or Loose” principle?	48	78.69	13	21.31
	Intervention approach is recommended to target cognitive impairments	35	57.38	26	42.62
	Goal Management Training	54	88.52	7	11.48
Overall average level of knowledge						72.76

No statistically significant difference was observed between the knowledge scores of the different health professions (p > 0.05). Furthermore, no significant correlation was found between clinical experience, whether general or specific to cognitive rehabilitation, and the level of knowledge (p > 0.05). Finally, the total knowledge score did not vary significantly according to the percentage of the caseload devoted to patients with ABI (p > 0.05). These results suggest that the level of professionals’ knowledge does not depend solely on their workload with ABI patients, which could indicate that other factors, such as continuing education and specific experience, play an important role in knowledge development.

Attitudes of professionals

Table 3 presents the attitudes of healthcare professionals regarding the assessment and intervention with people with ABI. Overall participants demonstrated positive attitudes toward the core principles of cognitive rehabilitation. A large majority of respondents recognized the importance of continuing education (98.36%), the need to adapt assessment tools to the Lebanese context (93.44%), and the value of combining multiple assessment tools to ensure accurate evaluation (90.16%). Individualized intervention planning was also strongly supported (98.36%).

Table 3.

The attitudes of health professionals

Statement	In agreement		Neither agree nor disagree		Disagree
	n	%	n	%	n	%
Early assessment and intervention of cognitive impairment following ABI is of clinical importance.	60	98.36	1	1.64	0	0.00
There is no absolute fixed model for the treatment of cognitive impairment following ABI.	39	63.93	9	14.75	13	21.31
If the results of the assessments show unimpaired cognitive function in a person who has suffered an ABI while signs of cognitive decline are perceived, cognitive rehabilitation should…	52	85.25	8	13.11	1	1.64
In clinical practice, many physicians are well aware of the importance of rehabilitation interventions for patients with ABI.	12	19.67	35	57.38	14	22.95
There are more advantages than disadvantages to treating TBIs with medication following ABI.	8	13.11	42	68.85	11	18.03
I assess the cognitive abilities of patients with ABI based on standardized assessments.	48	78.69	11	18.03	2	3.28
It is necessary to combine several assessment tools to obtain an accurate assessment of cognitive impairment.	55	90.16	5	8.20	1	1.64
I am not sure about the relevance of some of the assessment tools used by practitioners.	18	29.51	39	63.93	4	6.56
I have confidence in technology-assisted cognitive assessment tools (such as mobile apps or online platforms) to assess the abilities of patients with ABI.	9	14.75	37	60.66	15	24.59
There is a need to adapt assessment questionnaires to better meet the needs of ABI patients in the Lebanese context.	57	93.44	2	3.28	2	3.28
Effective cognitive intervention relies solely on training exercises that stimulate each impaired function.	34	55.74	19	31.15	8	13.11
An effective cognitive intervention must necessarily include several modalities.	55	90.16	6	9.84	0	0.00
I trust the reports of other professionals to assess certain cognitive functions, and I do not consider it necessary to repeat them.	12	19.67	31	50.82	18	29.51
Continuing education on the management of cognitive impairment in people with ABI is essential to improve clinical practices.	60	98.36	1	1.64	0	0.00
The use of technologies (such as virtual reality) may improve the effectiveness of cognitive rehabilitation for people with ABI.	44	72.13	16	26.23	1	1.64
When working with patients with ABI, it is important to apply intervention protocols as they are, without modifying them.	46	75.41	14	22.95	1	1.64
Collaboration with other healthcare professionals is essential for effective cognitive rehabilitation of patients with ABI.	59	96.72	2	3.28	0	0.00
When working with patients with ABI, it is essential to tailor the intervention plan according to the specific needs of each patient.	60	98.36	1	1.64	0	0.00

Attitudes also reflected strong support for approaches centered on interprofessional collaboration (96.72%) and the use of multimodal intervention modalities (90.16%). In contrast, only 13.11% of respondents believed that medication-based treatment offers more advantages in managing cognitive impairment. Similarly, while 55.74% considered targeted exercise sufficient, 31.15% adopted a neutral position and 13.11% indicated a preference for comprehensive and multimodal approaches. Trust in using technological-assisted tools, such as applications or digital platforms, was limited (14.75%).

Regarding clinical practices, most participants (78.69%) reported relying on standardized assessments, while 19.67% reported trusting evaluations conducted by other professionals. Most professionals (75.41%) reported following intervention protocols without modification, while allowing for a degree of clinical flexibility.

Practices of health professionals

The practices of healthcare professionals are presented across several domains, including assessment, intervention, documentation, and perceived challenges.

Assessment of cognitive functions

Memory, executive functions, and attention were the most frequently assessed cognitive domains, whereas visuospatial, linguistic, and self-awareness abilities were less systematically evaluated. Standardized tools including the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were widely used, informal assessments remained less employed.

Intervention modalities

Following the assessment of cognitive functions, participants reported a range of intervention approaches. Table 4 summarizes the intervention modalities employed by healthcare professionals in the cognitive rehabilitation of individuals with acquired brain injury. Cognitive skills training was the most frequently implemented approach (95.1%), followed by caregiver education (70.5%) and real-life work practice (60.7%). Environmental modifications and cognitive behavioral therapy were utilized by 37.7%. Although 26.2% of professionals reported incorporating new technologies into their interventions, barriers such as high cost and limited availability were cited by 30% of participants, and 22% indicated that these tools may not be suitable or adapted for all patients.

Table 4.

Intervention modalities used by health professionals

Intervention Methods	n	%
Cognitive skills training	58	95.08
Real Work Practice	37	60.65
Environmental changes	34	55.73
Cognitive behavioral therapy	23	37.70
Education for caregivers	43	70.49
Use of new technologies	16	26.23

Documentation

In addition to intervention practices, participants also described their documentation and evaluation procedures. Clinical practice guidelines and scientific articles were the primary resources used by professionals to guide their practice. A majority (90.2%) evaluated the effectiveness of cognitive rehabilitation using objective measures. Documentation practices varied, with many professionals reporting the use of formal reports (68.9%) and clinical records (55.7%).

Frequency of using certain cognitive assessments and intervention procedures

The frequency of use of these practices was also examined. Table 5 presents the frequency of selected assessment and intervention procedures. Standardized assessment tools were frequently used in clinical practice (77%), regarding knowledge updates, 91% of professionals report regularly updating assessment-related knowledge, and 85% report updating intervention-related knowledge.

Table 5.

Frequency of use of certain acts of cognitive assessment and intervention

	Always		Most of the time		Sometimes		Never
	(n)	%	(n)	%	(n)	%	(n)	%
Use of appropriate scales for assessment.	22	36%	25	41%	12	20%	2	4%
Updating knowledge on assessments.	26	43%	29	48%	6	10%	0	0%
Use of descriptive assessments and/or informal tools.	7	11%	31	51%	22	36%	1	2%
Raising awareness among patients and their families of the importance of cognitive rehabilitation.	39	64%	18	30%	4	7%	0	0%
Educating patients and families on how to train cognitive functions in their daily lives.	39	64%	15	25%	7	11%	0	0%
Update to develop skills related to interventions for cognitive disorders.	20	33%	32	52%	9	15%	0	0%
Regular adjustment of the intervention plan based on changes in cognitive abilities.	37	61%	22	36%	2	3%	0	0%
Use of multimodal interventions.	31	51%	18	30%	12	20%	0

However, the systematic use of descriptive assessments or informal tools remains limited, with only 11% reporting consistent use. Raising awareness among patients and families about the importance of cognitive rehabilitation appears to be well established, with 94% reporting engagement always or most of the time. Similarly, education on cognitive training modalities is widespread (89%). Adjusting the intervention plan based on client progress is also common (97%), reflecting individualized care. Finally, 81% of respondents reported employing multimodal interventions consistently, demonstrating recognition of the complexity of cognitive disorders. Nevertheless, 20% rarely apply multimodal interventions, likely due to organizational constraints, lack of resources, or insufficient training.

Use of standardized assessments

Approximately 77% of participants reported using standardized assessments always or most of the time in their clinical practice. Other frequently used instruments included the Functional Independence Measure (FIM) and Stroop Test. Barriers to the use of standardized tools included limited access, contextual constraints, and lack of cultural adaptation.

Challenges and training needs

Finally, participants reported several challenges and training needs related to cognitive rehabilitation. A majority (88.5%) identified the lack of validated tools for the Lebanese population as a major challenge. Additional obstacles included insufficient training (68.9%), limited access to standardized tools, restricted technological resources, and budget constraints. To improve cognitive rehabilitation practices, 85.2% of respondents highlighted the need for continuing education, 82% recommended locally adapted practice guides, 47.5% emphasized interprofessional collaboration, and 44.3% suggested subsidies for acquiring tools and resources.

A large majority (approximately 89%) of respondents emphasized the importance of continuing education, particularly in executive function rehabilitation, memory, and technology-based interventions. Professionals also expressed the need to enhance technical skills, including mastery of standardized assessment tools, development of evidence-based treatment protocols, and implementation of multimodal and compensatory strategies.

Discussion

This study aimed to explore the knowledge, attitudes, and practices of Lebanese healthcare professionals in the assessment and management of cognitive impairments in individuals with ABI. In the Lebanese context, where disparities in access to care persist, cognitive rehabilitation remains underdeveloped and inconsistently structured, with practices varying among professionals. These findings suggest the need for more standardized and context-adapted approaches to guide evidence-based service delivery in Lebanon.

The study included 61 Lebanese healthcare professionals working with adults with ABI, more than half of whom reported providing therapy services both in rehabilitation centers and in patients’ homes. This dual practice pattern may reflect the fragmented organization of rehabilitation services in Lebanon, and is consistent with findings from Kuwait, where professionals also reported working in mixed clinical contexts [26]. This fragmentation may be influenced by the predominantly private healthcare system, where services are largely funded by patients and their families, potentially limiting equitable access to structured cognitive rehabilitation services. Interestingly, no significant differences were observed in knowledge scores across professions, years of experience, or workload dedicated to cognitive rehabilitation. The findings suggest that clinical exposure alone may not be sufficient to ensure evidence-based practice, echoing findings from a Lebanese study on dysarthria, which also reported homogeneity across professionals [36]. This may highlight the importance of structured training and continuing education in shaping professional competencies. Few studies have examined healthcare professionals’ knowledge, attitudes, and practices of health professionals regarding cognitive dysfunction [8], and to our knowledge, none have specifically addressed ABI-related cognitive rehabilitation in Lebanon or the broader Arab region.

Overall, Lebanese professionals demonstrated a generally consistent level of theoretical knowledge, positive attitudes, and engagement in clinical practice, though notable gaps persist in the consistent use of standardized, evidence-based approaches [8, 25]. This apparent discrepancy may reflect the use of standardized protocols as a general framework, with individualized adaptations occurring informally or being constrained by contextual factors. The reliance on functional and measurable assessment criteria may reflect a pragmatic, performance-oriented approach in clinical settings. However, limited access to culturally and linguistically validated tools remains a major obstacle. The Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) were the most frequently used instruments, along with tools such as the FIM and Stroop tests. This pattern may reflect reliance on widely available tools despite their known limitations in non-Western contexts. These findings are consistent with international literature [8, 20, 21, 24, 27]. Nonetheless, the psychometric limitations of these instruments, particularly in non-Western populations, highlight the risk of misinterpretation and reduced diagnostic accuracy [6, 30]. For example, performance on tools such as the MoCA and MMSE may be influenced by educational level and language-related factors, potentially leading to underestimation of cognitive abilities in individuals with lower literacy or diverse linguistic backgrounds. This suggests the need to develop validated and standardized Arabic assessment tools adapted to the local cultural and clinical context.

The findings further indicate the need for clinical guidelines and specialized training programs to better structure cognitive rehabilitation practices. Recent evidence also highlights the positive impact of cognitive re-education on quality of life and psychological well-being in neurological populations, including individuals with multiple sclerosis [28], while regional evidence emphasizes the complexity of post-stroke sequelae, including cognitive impairments [13]. These findings further reinforces the importance of context-specific and culturally adapted neurorehabilitation protocols in the region [14, 15]. More specifically, continuing professional development initiatives should prioritize training in executive function rehabilitation, as this domain was identified as requiring further development. Training should also focus on the use of standardized and culturally adapted assessment tools, given the reported reliance on a limited number of non-adapted instruments. Finally, technology-based interventions should be further promoted, as they were underutilized despite generally positive attitudes toward their use.

Despite a rigorous methodology, certain limitations must be acknowledged. The use of an online self-administered questionnaire may have introduced recall bias and socially desirable responses [3, 22]. In addition, the mandatory completion of all questionnaire items may have introduced forced-response bias, as participants were required to provide an answer even when uncertain. The cross-sectional design prevents causal inference [1], and the absence of a national registry of healthcare professionals precluded calculation of an accurate response rate, limiting generalizability. The sample should therefore be interpreted as a convenience subgroup of relatively engaged healthcare professionals rather than a representative sample of all clinicians working with ABI in Lebanon. Consequently, the findings should be interpreted with caution and should not be generalized to all professions, regions, or service settings within the Lebanese context. In addition, the characteristics of non-respondents could not be assessed, which may introduce non-response bias. It is possible that individuals who did not participate or withdrew differed from respondents in terms of engagement, interest in cognitive rehabilitation, or workload. The relatively small sample size may also limit the representativeness of the findings, although these figures remain comparable to similar regional studies [26, 36]. The use of purposive sampling combined with recruitment through professional associations and social media may have introduced selection bias, potentially overrepresenting professionals with greater interest or engagement in cognitive rehabilitation and limiting the representativeness of the sample.

Furthermore, given the relatively small sample size (N = 61), the statistical power of the analyses may have been limited. Therefore, non-significant findings should be interpreted with caution, as they may reflect insufficient power rather than a true absence of associations. In addition, cross-domain analyses between knowledge, attitudes, and practices were not conducted, as the study was primarily designed to provide a descriptive overview of each domain rather than to examine inferential relationships. Such analyses could have provided further insight into the relationships between professionals’ perceptions and their actual clinical practices and should be considered in future research. Similarly, although participants expressed positive attitudes toward evidence-based and multimodal approaches, these were not consistently reflected in reported practices. This inconsistency may be particularly relevant in the Lebanese context, due to the limited access to validated tools, financial barriers, and variability in service organization. Such a discrepancy between reported knowledge and attitudes and actual clinical practices has been commonly described in KAP studies [1, 19].

Taken together, these findings suggest the need to develop validated and standardized Arabic assessment tools to improve the objectivity and quality of cognitive rehabilitation interventions. Furthermore, future research should investigate the impact of continuing education on professional practices, as well as the long-term effects of Lebanon’s economic crisis on the sustainability and accessibility of rehabilitation services. Overall, this study provides preliminary insights that may support the development of more structured, culturally adapted cognitive rehabilitation practices in Lebanon, and highlights the role of policymakers and educators in promoting interprofessional collaboration, training, and the integration of culturally relevant tools into practice.

Conclusion

This study provides the first systematic exploration of Lebanese healthcare professionals’ knowledge, attitudes, and practices regarding cognitive rehabilitation following acquired brain injury. While participants demonstrated a generally consistent level of knowledge and positive attitudes toward rehabilitation, the findings reveal significant challenges, particularly the scarcity of culturally validated assessment tools, limited specialized training opportunities, and the fragmented organization of service delivery within Lebanon’s privately funded healthcare system.

Addressing these gaps requires the development of standardized, culturally adapted Arabic assessment instruments, the implementation of structured and evidence-based continuing education programs, and the establishment of national clinical guidelines. More specifically, continuing professional development initiatives should prioritize training in executive function rehabilitation, the use of standardized and culturally adapted assessment tools, and technology-based interventions, which were identified as areas requiring further development. In addition, efforts should focus on improving access to validated tools and strengthening practical training to support the translation of knowledge and positive attitudes into consistent clinical practices. Such initiatives are essential to strengthen professional competencies, enhance the quality and equity of cognitive rehabilitation services, and align local practices with international standards.

Authors’ contributions

All three authors made substantial contributions to the conception and design of the study, as well as to data acquisition and manuscript drafting. M.S. and H.Z. performed the statistical analysis and contributed substantially to the interpretation of the data. The corresponding author supervised the study, coordinated the project, and ensured compliance with methodological and ethical standards. All authors critically revised the manuscript for important intellectual content, approved the final submitted version, and agree to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.

Data availability

The datasets are available from the corresponding author on reasonable request and with permission from the Institutional Review Board of Saint Joseph University of Beirut.

Declarations

Ethics approval and consent to participate

This study was reviewed and approved by the Institutional Review Board (IRB) of Saint Joseph University of Beirut (USJ), Lebanon (Approval No. USJ-2024-33). All procedures were conducted in accordance with the Declaration of Helsinki and relevant institutional guidelines. Participation was voluntary. An electronic informed consent form was presented at the beginning of the online questionnaire. Participants were required to indicate their consent before accessing the survey. No identifiable personal data was collected.

Consent for publication

The manuscript does not contain any individual person’s data in any form (including individual details, images, or videos).

Competing interests

The authors declare no competing interests.