Rehabilitation of Cognitive Deficits Poststroke: Systematic Review and Meta-analysis of Randomized Controlled Trials

Systematic Review and Meta-Analysis of Randomized Controlled Trials

Mairead O'Donoghue, BSc; Siobhan Leahy, PhD; Pauline Boland, PhD; Rose Galvin, PhD; John McManus, MD; Sara Hayes, PhD

Disclosures

Stroke. 2022;53(5):1700-1710. 

In This Article

Abstract and Introduction

Abstract

Background: Despite the prevalence of cognitive impairment poststroke, there is uncertainty regarding interventions to improve cognitive function poststroke. This systematic review and meta-analysis evaluate the effectiveness of rehabilitation interventions across multiple domains of cognitive function.

Methods: Five databases were searched from inception to August 2019. Eligible studies included randomized controlled trials of rehabilitation interventions for people with stroke when compared with other active interventions or standard care where cognitive function was an outcome.

Results: Sixty-four randomized controlled trials (n=4005 participants) were included. Multiple component interventions improved general cognitive functioning (MD, 1.56 [95% CI, 0.69–2.43]) and memory (standardized MD, 0.49 [95% CI, 0.27–0.72]) compared with standard care. Physical activity interventions improved neglect (MD, 13.99 [95% CI, 12.67–15.32]) and balance (MD, 2.97 [95% CI, 0.71–5.23]) compared with active controls. Noninvasive brain stimulation impacted neglect (MD, 20.79 [95% CI, 14.53–27.04) and functional status (MD, 14.02 [95% CI, 8.41–19.62]) compared with active controls. Neither cognitive rehabilitation (MD, 0.37 [95% CI, −0.94 to 1.69]) nor occupational-based interventions (MD, 0.45 [95% CI, −1.33 to 2.23]) had a significant effect on cognitive function compared with standard care.

Conclusions: There is some evidence to support multiple component interventions, physical activity interventions, and noninvasive brain stimulation improving cognitive function poststroke. Findings must be interpreted with caution given the overall moderate to high risk of bias, heterogeneity of interventions, and outcome measures across studies.

Introduction

Stroke is one of the leading causes of death and disability worldwide.[1] Cognitive impairment is reported in up to 57% of ischemic stroke survivors at 6 months poststroke[2] and is shown to be independently associated with lower quality of life,[3] higher rates of mortality and institutionalization,[4] increased carer burden,[5] and increased healthcare costs.[6]

A priority-setting partnership in the United Kingdom identified that cognitive impairment poststroke was among the top 10 research priorities for people living with stroke.[7] Recent international consensus-based core recommendations identify cognitive function poststroke as an area of unmet need for people poststroke.[8] However, much rehabilitation focus is placed on motor deficits, often neglecting hidden cognitive deficits.[9,10] For example, a meta-summary of qualitative studies exploring stroke survivors' experiences of rehabilitation found that an emphasis is placed on the rehabilitation of physical deficits over nonphysical needs such as social reintegration.[11]

As illustrated by the diversity and range of neuropsychological assessments, cognition is not a unitary concept.[12,13] Cognitive impairment poststroke encompasses a variety of deficits across multiple domains and typically includes memory, attention, executive function, language, and visuoperceptual ability.[14] Various cognitive domains enable complex mental processes to occur, which allow an individual to select and process information within their environment.[15]

Cognitive rehabilitation is defined as "a systematic functionally orientated intervention of therapeutic cognitive activities based on the assessment and understanding of the patient's brain behavior deficits".[15] Previous Cochrane reviews have explored the effectiveness of cognitive rehabilitation interventions on a specific domain of cognitive function poststroke, such as attention, memory, executive function, limb apraxia, neglect, and perception.[16–21]

An overview by Gillespie et al[22] synthesized evidence across these Cochrane reviews and reported favorable outcomes of cognitive rehabilitation across the domains of attention, spatial neglect, and motor apraxia immediately postintervention, but these improvements are not likely to persist in the long term and do not improve the everyday functioning of the individual poststroke.[22]

Focusing on outcomes relating to any single domain of cognitive function poststroke may be overly simplistic, given the often diffuse and interconnected cognitive impairments present in individuals poststroke.[23] Studies focusing on the rehabilitation of single cognitive domains fail to capture the interrelated and highly overlapping nature of cognitive domains.[12,23,24] There remains a need to move beyond the narrow scope of specific cognitive rehabilitation interventions focusing on one specific domain of cognitive function. A breadth of intervention modalities impact cognitive function for people living with stroke, including virtual reality training, physical activity interventions and neuro-feedback therapy,[25–27] and many more. Given the known interactions of cognitive domains required for optimal function and quality of life poststroke, alongside the broad range of possible interventions, the effects of interventions across all domains of cognitive function poststroke requires examination.

To our knowledge, there is no systematic review that has examined the effectiveness of all types of rehabilitation interventions, across multiple domains of cognitive function poststroke. Therefore, in addition to general cognitive function, this review includes outcomes on cognitive deficits across the domains of attention, memory, executive function, perception, limb apraxia, and neglect, and examines the effectiveness of nonpharmacological rehabilitation interventions across these multiple domains of cognitive function poststroke.

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