Cognitive Rehabilitation

Evidence Reviewed as of before: 20-04-2017

Author(s)*: Tatiana Ogourtsova, MSc BSc OT; Adam Kagan, B.Sc.; Amy Henderson, PhD Student, Neuroscience; Nicol Korner-Bitensky PhD OT

Editor(s): Annabel McDermott, OT

Patient/Family Information

Introduction

Cognitive skills are characterized as basic mental abilities, including a wide variety of mental processes. For example, perception, memory, problem solving, attention, body awareness in addition to many others. Cognitive abilities can be perceived as fundamental processes since they can shape social, emotional, as well as academic learning. In individuals who have sustained a stroke, these skills may be altered resulting in deficits in several areas of functioning such as communication, self-care, productivity and leisure. Cognitive rehabilitation is based upon scientific theories that have been derived from various disciplines including cognitive neuroscience, neuropsychology, neurolinguistics, and language and cognitive development. It is a treatment that comprises both medical and therapeutic services, specifically aimed at restoring as many cognitive functions as possible while proposing different compensatory strategies to more fully cope with cognitive deficits. The aim of this module is to address the effectiveness of cognitive rehabilitation for improving attention deficits and memory in patients who have suffered a stroke.

Patient/Family Information

What is cognitive rehabilitation?

Cognitive rehabilitation is a goal-oriented program that aims to improve cognitive functions (memory, attention, and concentration) and daily living skills (i.e. using the telephone, managing medication, and handling money) that may have been affected by your stroke. The rehabilitation program is developed according to each client’s specific needs. The goal is to improve performance in tasks that are important to you. Two approaches are usually adopted: the remedial (or restorative) approach and the compensatory approach.

www.brainsource.com/brain_rehabilitation.htm

Why use cognitive rehabilitation after a stroke?

Cognitive impairment, a problem involving the mind, is very common following a stroke. There are different kinds of cognitive impairment, such as forgetfulness, confusion, and/or disorientation, which can interfere with safety, productivity, independence and personal relationships.

Cognitive rehabilitation has been developed by physicians, scientists, and health professionals to improve cognitive function. This therapy also aims to help people with cognitive dysfunction deal with the impact it has on their lives. With the help of cognitive rehabilitation, many people can have a productive and satisfying life following a stroke.

What can I expect before I start therapy?

Your cognitive rehabilitation therapy treatment will be based on your own individual goals and will consider all of your strengths and weaknesses in cognitive function. There are several techniques that can help you to achieve the goals of your treatment, such as auditory and/or visual attentional tasks and memory training. You may be asked to take a variety of neuropsychological tests in order to determine your current cognitive functioning. This will help your therapists develop a suitable treatment plan. Some of these tests may seem to ask silly questions or you may feel nervous trying to answer correctly. Remember that the most important thing before starting therapy is for you and your therapist to understand where you need to focus your therapy efforts. So try to keep that in mind when doing the various tests.

How does the restorative (remedial) approach work?

The goal of this approach is to restore the cognitive functions that have been impaired by a stroke. It involves practicing the skills with which you have difficulty until you see improvement. The goal is for you to eventually be able to apply the skills you have learned in therapy to real life situations. The restorative approach involves 3 formats: Drill and practice This method is used to reinforce your cognitive capacities through repetitive practice. You can retrain yourself to perform tasks by practicing them over and over until you have mastered them. For example, to relearn a task such as making coffee, you would formulate a series of steps (filling the container with water, grinding the coffee, turning on the machine, etc) and then practice these steps until it becomes second nature once again.

Mnemonic Strategies These are tricks used to help remember specific information such as telephone numbers, vocabulary, appointments. They can also help you to learn new information. Your therapist will help you develop these tricks and you may already have some of your own that you have used in the past. Mnemonic strategies include: Verbal mnemonic strategies Words are used to aid memory. They encompass the use of:

Acronyms: These are abbreviations in which each letter stands for the first letter in the list of words you want to remember. For example, the word ‘HOMES’ can help you remember the names of the Great Lakes: Huron, Ontario, Michigan, Erie, and Superior.
Rhymes: Rhymes are useful in helping to remember facts, such as : “Fourteen hundred and ninety-two, Columbus sailed the ocean blue”
Songs: Songs like the “Alphabet Song” are great for learning and memory – a,b,c,d e,f,g, h,i, j, k, etc.
Acrostics: These are similar to acronyms, but instead of only one word per letter, there can be a sentence assigned to each letter.
Verbal stories: Often explaining something out loud as a story is a useful memory tool.
Coding methods: There are many ways of using code, such as transforming numbers into letters.
http://coe.jmu.edu/LearningToolbox/images/homes.gif

Imagery mnemonic strategies In this form of memory building, visual images are used to aid memory. The best known techniques are the list learning strategies. They include 4 methods:

The method of loci or place method: This is a mnemonic strategy that is very effective for remembering lists. To use this method you choose a place that you are very familiar with (your house for example). Think of different landmarks in that place (the bathroom, the kitchen, the hall, etc) and train yourself to go around the landmarks in a particular order. Let’s say you are trying to remember a shopping list. Imagine each of the items on the list in one of the landmarks you have in mind. For example, you may picture a giant carton of milk on the couch, or a huge banana in the bathtub.
The numeric Pegword method: This method is useful for remembering numbered or ordered information. It involves rhyming words for numbers, since the words may be easier to remember in association with what you are trying to learn. This way, instead of having to memorize numbers, you picture the word associated with them. For example:
- one is bun
- two is shoe
- three is tree
- four is door
- five is hive etc.
The link method: This is when you make simple associations between items in a list, linking them with an image containing all of the items. For example, if the first item on the list was a dog and the second was a motorcycle, then you may try to visualize a dog riding a motorcycle. The fact that this image is bizarre and impossible will help you to remember it.
The visual story method: This involves linking items together in a memorable story. For example, you may try to remember the planets in order of distance from the sun: “As the heat comes off the SUN, the MERCURY in the thermometer rises. Then the thermometer explodes and the mercury droplets fall onto a beautiful goddess named VENUS. To hide form the mercury droplets, Venus digs a big hole in the EARTH….”. http://www.mindtools.com/pages/article/newTIM_01.htm

Computer-based tools Virtual reality Virtual reality is a technology that allows a user to interact with a computer-simulated environment. Examples of cognitive skills that can be improved using virtual reality a

Short-term memory: the capacity to remember information for a short period of time
Selective attention: the ability to concentrate on and perform activities while filtering out other distractions
Sustained memory: the ability to remain focused for a length of time.
Divided attention: the capacity to attend to two or more stimuli at the same time.

Other computerized tools Computer software exists to work on different cognitive abilities such as visual memory, verbal memory, attention to visual objects etc.. Activities to work on these functions include the use of numbers, letters, words, and shape sequences. NOTE: Don’t be concerned if you are not familiar with computers – these programs work quite simply and your therapist can show you how to use them easily.

Is restorative therapy effective?

There has not been a lot of research on cognitive retraining for memory and attention. We need more studies before we can say how effective this treatment is for retraining cognitive skills after a stroke.

How does the compensatory approach work?

The compensatory approach is another type of cognitive rehabilitation used with people who have had a stroke. You or your therapist may turn to the compensatory approach when efforts to restore cognitive function are not working well. Compensatory strategies can be taught by an occupational therapist, a physiotherapist, or a speech-language pathologist. Family members can also help you find ways to facilitate daily activities. It is important to be creative when coming up with compensatory techniques. Let people know your preferences in terms of strategies when planning compensatory techniques. http://www.isabella.org/images/rehab-SpeechTherapy.jpg Compensatory strategies include making changes in your environment (home, school, workplace, etc) or adopting different methods of performing activities. As well, compensatory strategies involve making use of devices that help with remembering tasks, for example there are many options on wrist-watches and other innovative gadgets that can remind you about a scheduled activities (e.g. visiting a loved one). Other examples of compensatory strategies for memory might be to use an agenda book, a diary or a tape recorder to help to remember things to do.

Is compensatory therapy effective?

Compensatory strategies can possibly work for anyone who has experienced a stroke but may be more effective if the person is young and has only one or two cognitive issues (i.e. compensation strategies will work better for someone with only a memory problem than for someone with a memory and a concentration problem). One good quality research study looked at compensatory strategies and their effect on performance of everyday activities in people with stroke. The results showed improvement in the time and quality of performance of every day activities.

External links to helpful sites on cognitive rehabilitation

For further details on the different mnemonic strategies, please visit this link: http://www.memory-key.com/Mnemonics/mnemonics.htm

For the link and story method: http://www.mindtools.com/pages/article/newTIM_01.htm

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

Currently, many approaches are used to restore cognitive processes in patients with post-stroke cognitive deficits. These methods include the Cognitive Orientation to daily Occupational Performance (CO-OP) approach, compensatory strategies (e.g. pager system), computer training, various types of attention training and memory training and more recently, virtual reality.

This review of cognitive rehabilitation following stroke includes six high quality RCTs, eight fair quality RCTs, one poor quality RCT and two non-randomized crossover study.

Studies that were not considered suitable for inclusion in this module are identified in the reference list. All outcomes measures referring to executive functions are not included in the in-depth review on this module; Please see the Executive Functions Intervention module for more details on these outcomes.

Results Table

View results table

Outcomes

Acute phase - Attention training + cutaneous electrical stimulation

Functional independence

Not effective

One fair quality RCT (Giaquinto & Fraioli, 2003) investigated the effect of cognitive rehabilitation using attention training with electrical stimulation on functional independence in patients with acute stroke. This fair quality RCT randomized patients to receive attention training + cutaneous electrical stimulation or no training. Functional independence was measure by the Functional Independence Measure (FIM) post-treatment (3 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using attention training + cutaneous electrical stimulation is not more effective than no training in improving functional independence in patients with acute stroke.

Somatosensory function

Effective

One fair quality RCT (Giaquinto & Fraioli, 2003) investigated the effect of cognitive rehabilitation using attention training with electrical stimulation on somatosensory function in patients with acute stroke. This fair quality RCT randomized patients to receive attention training + cutaneous electrical stimulation or no training. Somatosensory function (N140 event related potential) was measured by electroencephalographic signals (EEG) at post-treatment (3 weeks). Significant between-group differences were found, favoring attention training + cutaneous electrical stimulation vs. no training

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using attention training + cutaneous electrical stimulation is more effective than no training in improving somatosensory function (N140 ERP) in patients with acute stroke.

Subacute phase - Memory retraining

Memory

Not effective

One fair quality RCT (Doornhein & De Haan, 1998) investigated the effect of a cognitive rehabilitation memory retraining program on memory in patients with subacute stroke. This fair quality RCT randomized patients to receive cognitive rehabilitation using a memory retraining program or a non-specific memory training program. Memory was measured by the Name-Face Paired Associated Memory Test, the Stylus Maze Test, 15 Word Test and the Oxford Recurring Faces Test at post-treatment (4 weeks). A significant between-group difference was found in only one measure of memory (Name-Face Paired Associated Memory Test), favoring the memory retraining programme vs. the non-specific memory training program.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that a cognitive rehabilitation memory retraining programme is not more effective than a comparison intervention (non-specific memory training) in improving memory in patients with subacute stroke.

Self-reported memory

Not effective

One fair quality RCT (Doornhein & De Haan, 1998) investigated the effect of a cognitive rehabilitation memory retraining program on self-reported memory in patients with subacute stroke. This fair quality RCT randomized patients to receive a cognitive rehabilitation memory retraining program or a non-specific memory training programme. Self-reported memory was measure by the 41-item Memory Questionnaire at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation memory retraining is not more effective than a comparison intervention (non-specific memory training) in improving self-reported memory in patients with subacute stroke.

Subacute phase - Sustained attention training

Alertness and attention

Effective

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on attention deficits in patients with subacute stroke. This non-randomized crossover study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Alertness and sustained attention were measured at 12-week follow-up using the Wiener Determinationsgerat, Wiener Reaktionsgerat, Wiener Vigilanzgerat and the Test d2. There was a significant improvement in one measure of alertness (Wiener Determinationsgerat) and one measure of sustained attention (Wiener Vigilanzgerat), in favour of attention training vs. no training.
Note: Results presented above were obtained from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Conclusion: There is limited evidence (Level 2b) from one non-randomized crossover study that cognitive rehabilitation using sustained attention training is more effective than no training in improving some measures of alertness and sustained attention in patients with subacute stroke.

Memory

Not effective

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on memory in patients with subacute stroke. This non-randomized crossover study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Memory was measured by the Cognitrone (pattern recognition), Wechsler Adult Intelligence Scale (similarities subscale), Intelligenz-Struktur-Test (similarity recognition) and the Raven Standard Progressive Matrices (pattern completion ability) at 12-week follow-up. No significant between-group differences were found.
Note: Results presented above are from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Conclusion: There is limited evidence (Level 2b) from one non-randomized crossover study that cognitive rehabilitation using sustained attention training is not more effective than no training in improving memory in patients with subacute stroke.

Reasoning

Not effective

One non-randomized study (Sturm et al., 1991) investigated the effect of sustained attention training on reasoning in patients with subacute stroke. This non-randomized cross-over study assigned patients to first receive sustained attention training or no training for three weeks, followed by a cross-over period for a further three weeks. Reasoning was measured by the Leistungsprufsystern at 12-week follow-up. No significant between-group differences were found.
Note: Results presented above are from a systematic review by Lincoln et al., (2000), for the purpose of clarity.

Chronic phase - Attention process training

Attention

Effective

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on attention in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Attention was measured by the Integrated Visual Auditory Continuous Performance Test (IVA-CPT – Full Scale Attention Quotient, Auditory attention and Visual attention subtests) at post-treatment (4 weeks) and at 6-month follow-up. At post-treatment there were significant between-group differences in scores on the full attention scale and auditory attention subtest; at 6-month follow-up results remained significant for the measure of full attention only, favoring attention process training vs. usual care.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is more effective than usual care in improving attention in patients with chronic stroke.
Note: There were no significant differences between groups in tests of visual attention.

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on auditory information processing speed in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Auditory information processing speed was measured by the Paced Auditory Serial Addition Test at post-treatment (4 weeks) and 6-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving auditory information processing speed in patients with chronic stroke.

Auditory information processing

Not effective

Functional independence

Not effective

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on functional independence in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Functional independence was measured by the Modified Rankin Scale at 6-month follow-up; measures were not taken at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving functional independence in patients with chronic stroke.

Memory

Not effective

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on memory in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Self-reported memory failure was measured by the Cognitive Failure Questionnaire at 6-month follow-up; measures were not taken at post-treatment (4 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving self-reported memory failure in patients with chronic stroke.

Quality of life

Not effective

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on quality of life in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Quality of life was measured by the Short Form 36 (SF-36 – Physical Component Score, Mental Component Score) at post-treatment (4 weeks) and at 6-month follow-up, and by the General Health Questionnaire (GHQ-28) at follow-up (6 months) only. No significant between-group differences were found at either time point.

Unilateral spatial neglect

Not effective

One high quality RCT (Barker-Collo et al., 2009) investigated the effect of attention process training on unilateral spatial neglect in patients with chronic stroke. This high quality RCT randomized patients to receive attention process training or usual care. Unilateral spatial neglect was measured by the Bells Test at post-treatment (4 weeks) and 6-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using attention process training is not more effective than usual care in improving unilateral spatial neglect in patients with chronic stroke.

Chronic phase - Cognitive Orientation to Occupational Performance (CO-OP)

Task performance

Effective

One fair quality RCT (Polatajko et al., 2012) investigated the effect of the CO-OP approach on task performance in patients with chronic stroke. This fair quality RCT randomized patients to receive the CO-OP approach or conventional occupational therapy. Task performance was measured by the Performance Quality Rating Scale (PQRS) and the Canadian Occupational Performance Measure (COPM – Performance, Satisfaction) at post-treatment (10 sessions). Significant between-group differences in task performance were found at post-treatment (PQRS, COPM – Performance), favoring CO-OP vs. conventional occupational therapy.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the CO-OP approach is more effective than conventional occupational therapy in improving task performance in patients with chronic stroke.
Note: There were no significant between-group differences in participants’ satisfaction with task performance, as measured by the COPM.

Chronic phase - Memory self-efficacy training

Delayed recall

Not effective

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on delayed memory recall in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Delayed recall was measured by the Auditory Verbal Learning Test and the Rivermead Behavioral Memory Test (story recall – delayed) subtests at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is not more effective than a comparison intervention (peer support stroke education program) in improving delayed memory recall in patients with chronic stroke.

Depression

Not effective

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on depression in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Depression was measured by the Center of Epidemiological Studies – Depression Scale at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Memory self-efficacy

Effective

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on MSE in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Memory self-efficacy was measured by the Metamemory-In-Adulthood Questionnaire at post-treatment (approximately 5 weeks). Significant between-group differences were found, favoring MSE training vs. a peer support education program.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is more effective than a comparison intervention (peer support stroke education program) in improving memory self-efficacy in patients with chronic stroke.

Quality of life

Effective

One high quality RCT (Aben et al., 2013) investigated the effect of memory self-efficacy (MSE) training on quality of life in patients with chronic stroke. This high quality RCT randomized patients to MSE group training or a peer support stroke education program. Quality of life was measured by the EuroQol EQ5D Questionnaire (utility score and visual analogue scale) and the WhoQoL Brief Questionnaire (psychological quality of life, social quality of life scores) at post-treatment (approximately 5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using MSE group training is not more effective than a comparison intervention (peer support strokeeducation program) in improving quality of life in patients with chronic stroke.

Chronic phase - Pager system

Memory

Effective

One fair quality randomized crossover trial (Fish et al., 2008) investigated the effect of a pager system on memory in patients with chronic stroke. This fair quality RCT randomized patients to use the NeuroPager system or no treatment in a crossover design. Memory was measured by memory diaries (percentage of tasks achieved) at T2 (7 weeks) and T3 (14 weeks). At both post-treatment time points there were significant between-group differences in favour of the group that had just completed the NeuroPager trial. Memory gains were not maintained over time without use of the NeuroPager system.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the NeuroPager system is more effective than no treatment in improving memory in patients with chronic stroke.

Chronic phase - Virtual reality

Attention

Effective

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on attention in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Attention was measured by the Addenbrooke Cognitive Examination (ACE – Attention) at post-treatment (4-6 weeks). Significant between-group differences were found, favoring VR-based cognitive rehabilitation vs. conventional cognitive rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is more effective than a comparison intervention (conventional cognitive rehabilitation) in improving attention in patients with chronic stroke.

Cognition

Effective

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on cognition in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Cognition was measured by the Mini-Mental State Examination (MMSE) and the Addenbrooke Cognitive Examination (ACE – total score, fluency, language, visuospatial subscores) at post-treatment (4-6 weeks). Significant between-group differences were found (MMSE; ACE – total, fluency), favoring VR-based cognitive rehabilitation vs. conventional cognitive rehabilitation.

Memory

Not effective

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on memory in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program or conventional cognitive rehabilitation. Memory was measured by the Addenbrooke Cognitive Examination (ACE – memory) at post-treatment (4-6 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that VR-based cognitive rehabilitation is not more effective than a comparison intervention (conventional cognitive rehabilitation) in improving memory in patients with chronic stroke.

Stroke outcomes

Not effective

One high quality RCT (Faria et al., 2016) investigated the effects of virtual-reality (VR)-based cognitive rehabilitation on stroke outcomes in patients with chronic stroke. This high quality RCT randomized patients to receive VR-based cognitive rehabilitation using the Reh@City simulation program, or conventional cognitive rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale at post-treatment (4-6 weeks). No significant between-group differences were found.

Phase not specific to one period - CO-OP

Community participation

Effective

One fair quality RCT (McEwen et al., 2015) investigated the effect of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach on community participation in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Community participation was measured by the Community Participation Indicator (CPI) (Importance of participation, Control over participation, Satisfaction with participation scales) at post-treatment (10 sessions) and at follow-up (3 months); the measure was not used at baseline. Comparison of change scores from post-treatment to follow-up revealed a medium effect size (CPI – Control over participation only), favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP approach is more effective than a comparison intervention (conventional rehabilitation) in improving an individual’s sense of control over community participation among patients with acute/subacute stroke.
Note: There were no significant differences in an individual’s perceived importance of, or satisfaction with, community participation.

Occupational performance

Not effective

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on occupational performance in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Occupational performance was measured by the Canadian Occupational Performance Measure (COPM – Performance trained and untrained tasks, Satisfaction trained and untrained tasks) at post-treatment (10 sessions) and at 3-month follow-up. Comparison of change scores from baseline to post-treatment indicated no significant treatment effect; scores at follow-up revealed only small effect sizes (COPM – Performance trained and untrained tasks, Satisfaction untrained tasks only), favouring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that cognitive rehabilitation using the CO-OP approach is not more effective than a comparison intervention (conventional rehabilitation) in improving occupational performance in patients with acute/subacute stroke.

Self-efficacy

Effective

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on perceived self-efficacy in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Perceived self-efficacy was measured by the Self Efficacy Gauge at baseline, at post-treatment (10 sessions) and at 3-month follow-up. While there was no significant effect from baseline to post-treatment, comparison of scores from post-treatment to follow-up revealed a medium treatment effect, favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that the CO-OP treatment is more effective than a comparison intervention (conventional rehabilitation) in improving self-efficacy in patients with acute/subacute stroke.

Stroke outcomes

Effective

Two fair quality RCTs (Wolf et al., 2016, McEwen et al., 2015) investigated the effect of the CO-OP approach on stroke outcomes in patients with stroke.

The first fair quality RCT (Wolf et al., 2016) randomized patients with acute/subacute stroke to receive CO-OP or conventional occupational therapy. Stroke outcomes were measured by the Stroke Impact Scale (ADLs, Mobility, Hand Function, Strength, Recovery, Physical, Memory, Emotion, Communication) at post-treatment (10 sessions) and at 3-month follow-up. Results at post-treatment showed medium to large treatment effect sizes (SIS – ADLs, Hand Function, Strength, Recovery, Physical, Memory, Emotion, Communication), favoring CO-OP vs. conventional occupational therapy. At follow-up, medium effects were maintained for two stroke outcomes (SIS – Hand Function, Communication), favoring CO-OP vs. conventional occupational therapy.

The second fair quality RCT (McEwen et al., 2015) randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale (SIS – Participation subscale only) at post-treatment (10 sessions) and at 3-month follow-up; the measure was not used at baseline. Comparison of change scores from post-treatment to follow-up revealed a medium treatment effect size, favoring CO-OP vs. conventional rehabilitation.

Conclusion: There is limited evidence (Level 2a) from two fair quality RCTs that the CO-OP approach is more effective than a comparison intervention (conventional therapy) in improving aspects of stroke outcomes in patients with acute/subacute stroke.

Task performance

Effective

One fair quality RCT (McEwen et al., 2015) investigated the effect of the CO-OP approach on task performance in patients with stroke. This fair quality RCT randomized patients with acute/subacute stroke to receive CO-OP or conventional rehabilitation. Performance of self-selected activities was measured by the Performance Quality Rating Scale (PQRS – Trained tasks, Untrained tasks) at post-treatment (10 sessions) and at 3-month follow-up. Medium to large effect sizes were found for performance of trained and untrained tasks at post-treatment and at follow-up, favoring CO-OP vs. conventional rehabilitation.

Phase not specific to one period - Computer training

Attention

Effective

One high quality RCT (Prokopenko et al., 2013) and one non-randomized study (Sturm et al., 1997) investigated the effect of cognitive rehabilitation using computer training on attention in patients with stroke.

The high quality RCT (Prokopenko et al., 2013) randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Attention was measured by Shulte’s test at post-treatment (2 weeks). Significant between-group differences were found, favoring computer training vs. conventional rehabilitation.

The non-randomized study (Sturm et al., 1997) assigned patients with subacute/chronic stroke to receive computerized attention training. Participants received training that specifically targeted two domains of attention (alertness, vigilance, selective attention or divided attention), according to each participant’s two most impaired domains. Attention was measured at baseline and at post-treatment 1 and post-treatment 2 (i.e. after each 14-session training period) using a computerised attention test battery (alertness: response time with/without warning signal; vigilance: hit-rate, response with warning; selective attention: error rate, response time with warning; divided attention: error rate, response time with warning). There were significant improvements in attention (alertness: response time without warning signal; vigilance: hit-rate; selective attention: response time with warning; divided attention: error rate); results showed a domain-specific training effect (e.g. improved alertness was only achieved following alertness training).

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using computer training is more effective than a comparison interventions (conventional therapy) in improving attention in patients with stroke. A non-randomized study also reported improved attention skills following computerized attention training.

Cognition

Not effective

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on cognition in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Cognition was measured by the Mini-Mental State Examination and the Montreal Scale of Cognitive Assessment at post-treatment (2 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using neuropsychological computer training is not more effective than a comparison intervention (conventional therapy) in improving cognition in patients with stroke.

Mood

Not effective

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on depression and anxiety in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Mood was measured by the Hospital Anxiety and Depression Scale at post-treatment (2 weeks). No significant between group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuropsychological computer training is not more effective than a comparison intervention (conventional therapy) in improving mood in patients with acute/subacute stroke.

Visuospatial skills

Effective

One high quality RCT (Prokopenko et al., 2013) investigated the effect of computer training on visuospatial skills in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive neuropsychological computer training or conventional rehabilitation. Visuospatial skills were measured by the Clock Drawing Test at post-treatment (2 weeks). Significant between-group differences were found, favoring computer training vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that neuropsychological computer training is more effective than a comparison intervention (conventional therapy) in improving visuospatial skills in patients with acute/subacute stroke.

Phase not specific to one period - Global attention processing training

Visuospatial memory

Effective

One fair quality RCT (Chen et al., 2012) investigated the effect of global attention processing training on visuospatial memory in patients with acute/subacute stroke. This fair quality RCT randomized patients to receive global attention processing training (i.e. global to local encoding strategy) or rote repetition training (no encoding strategy) to learn the Rey-Osterrieth Complex Figure (ROCF) in one training session. Visuospatial memory was measured with the ROCF – immediate recall, delayed recall and configural organization subtests: immediately post-training (ROCF – immediate recall/configural organization); at 30 minutes post-training (ROCF – delayed recall/configural organization); and at 1 day, 2 weeks and 4 weeks post-training (ROCF – immediate recall/delayed recall/configural organization). Significant between-group differences were found immediately post-training (ROCF – immediate recall), at 30 minutes post-training (ROCF – delayed recall), and at 1 day post-training (ROCF – immediate recall/configural organization), favoring global attention processing training vs. rote repetition training. There were no significant differences between groups on any measure of visuospatial memory at 2 weeks or 4 weeks post-training.

Conclusion: There is limited evidence (Level 2b) from one fair quality RCT that global attention processing training is more effective than a comparison intervention (rote repetition training with no encoding strategy) in improving visuospatial memory in patients with acute/subacute stroke.

Phase not specific to one period - Time pressure management

Fatigue

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on fatigue in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Fatigue was measured by the Fatigue Severity Scale at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving fatigue in patients with subacute/chronic stroke.

Functional Independence

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on functional independence/ADLs in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Functional independence was measured by the Barthel Index at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Information processing

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on information processing in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional therapy. Information processing was measured at post-treatment (10 hours of treatment) and at 3-month follow-up using the Information Intake Task (IIT: no. of strategies used, reproduction scores), the Mental Slowness Observation Test (MSOT – no. of used strategies, no. of correct elements, time), the Mental Slowness Questionnaire, Symbol Digit Modalities Test and the Paced Auditory Serial Addition Task. Significant between-group differences were found on only one measure at post-treatment (ITT – number of strategies used) and at follow-up (MSOT – time), favoring time pressure management vs. conventional rehabilitation.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that cognitive rehabilitation using a time pressure management approach is not more effective than a comparison intervention (conventional therapy) in improving information processing in patients with subacute/chronic stroke.

Memory

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on memory in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Memory was measured by the Auditory Verbal Learning Test at post-treatment (10 of hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Mood

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on mood in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Depression was measured by the Center for Epidemiologic Studies Depression Scale at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Quality of life

Not effective

One high quality RCT (Winkens et al., 2009) investigated the effect of cognitive rehabilitation using a time pressure management approach on quality of life in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive time pressure management or conventional rehabilitation. Quality of life was measured by the EuroQol-5D at post-treatment (10 hours of treatment) and at 3-month follow-up. No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that a time pressure management approach is not more effective than a comparison intervention (conventional rehabilitation) in improving quality of life in patients with subacute/chronic stroke.

Phase not specific to one period - Virtual Reality

Attention

Effective

One poor quality RCT (Gamito et al., 2015) investigated the effect of virtual-reality (VR)-based cognitive rehabilitation on attention in patients with stroke. This poor quality RCT randomized patients with stroke (stage of stroke not specified) to receive VR-based cognitive rehabilitation or no treatment. Sustained attention was measured by the Toulouse-Pieron Test (work efficiency) at post-treatment (4-6 weeks). Significant between-group differences were found, favoring VR-based cognitive rehabilitation vs. no treatment.

Conclusion: There is limited evidence (Level 2b) from one poor quality RCT that VR-based cognitive rehabilitation is more effective than no treatment in improving sustained attention in patients with stroke.

Memory

Effective

One fair quality RCT (Rose et al., 1999) and one poor quality RCT (amito et al., 2015G) investigated the effect of virtual-reality (VR)-based cognitive rehabilitation on memory in patients with stroke.

The fair quality RCT (Rose et al., 1999) randomized patients with stroke (stage of stroke not specified) to receive active VR-based memory retraining program or passive VR-based memory retraining. Memory was measured using spatial and object recognition tests at post-treatment (1 training session). A significant between-group difference in one measure of memory (spatial recognition test) was found, favoring the active VR-based memory retraining program.

The poor quality RCT (Gamito et al., 2015) randomized patients with stroke (stage of stroke not specified) to receive VR-based cognitive rehabilitation or no treatment. Memory was measured by the Wechsler Memory Scale (WMS total score) and the Rey-Osterieth Complex Figure (ROCF – immediate recall) at post-treatment (4-6 weeks). Significant between-group differences in memory (WMS total score only) were found, favoring VR-based cognitive rehabilitation vs. no treatment.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT and one poor quality RCT that VR-based cognitive rehabilitation is more effective than comparison interventions (passive VR-memory retraining program, no treatment) in improving memory in patients with stroke.

Phase not specific to one period - Visual Attention Training

Attention

Not Effective

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Attention was measured by the Test of Everyday Attention at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving attention in patients with subacute/chronic stroke.

Driving

Not Effective

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on driving abilities in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Driving abilities were measured by the on-road driving evaluation at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving on-road driving abilities in patients with subacute/chronic stroke.

Unilateral spatial neglect

Not Effective

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on unilateral spatial neglect (USN) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. USN was measured by the Single and Double Letter Cancellation Test and the Bells Test at post-treatment (5 weeks). No significant between-group differences were found.

Visual attention

Not Effective

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on visual attention in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Visual attention was measured by the UFOV test (total, processinSg speed, divided attention, selective attention), and the complex reaction timer (Charron Test) at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving visual attention in patients with subacute/chronic stroke.

Visual perception

Not Effective

One high quality RCT (Mazer et al., 2003) investigated the effect of visual attention training on visual perception in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive Useful Field of View (UFOV) visual attention training or traditional computerized visuoperception training. Visual perception was measured by the Motor-Free Visual Perception Test at post-treatment (5 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that UFOV visual attention training is not more effective than a comparison intervention (traditional computerized visuoperception training) in improving visual perception in patients with subacute/chronic stroke.

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Excluded Studies

Cantagallo, A., Maini, M., & Rumiati, R.I. (2012). The cognitive rehabilitation of limb apraxia in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Neuropsychological Rehabilitation, 22 (3), 473-88.

Reason for Exclusion: Review

Gray JM, Robertson I, Pentland B, Anderson S. (1992). Microcomputer-based attentional retraining after brain damage: A randomised group controlled trial. Neuropsychological Rehabilitation, 2, 97-115.

Reason for Exclusion: Sample includes other etiology than strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Hildebrandt, H., Bussmann-Mork, B., & Schwendemann, G. (2006). Group therapy for memory impaired patients: a partial remediation is possible. Journal of Neurology, 253(4), 512-519.

Kaschel R., Della Sala S., Cantagallo A., Fahlbock A., Laaksonen R. & Kazen M. (2002). Imagery mnemonics for the rehabilitation of memory: a randomised group controlled trial. Neuropsychological Rehabilitation, 12(2), 127-53.

Reason for Exclusion: Participants with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. represent less than 50% of overall studied sample.

Miller, L. A., & Radford, K. (2014). Testing the effectiveness of group-based memory rehabilitation in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients. Neuropsychological Rehabilitation, 24(5), 721-737.

Reason for Exclusion: Not a RCTA randomized controlled trial (RCT) is an experimental design in which subjects are randomly assigned to a treatment group, or to a control (no treatment or alternative treatment) group. Effects of the experimental treatment are then compared statistically to results of the control treatment to determine effectiveness., outcomes available in RCTs.

Mount, J., Pierce, S. R., Parker, J., DiEgidio, R., Woessner, R., & Spiegel, L. (2007). Trial and error versus errorless learning of functional skills in patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. NeuroRehabilitation, 22(2), 123-132.

Reason for Exclusion: Executive functions training, refer to executive function interventions module.

Ostwald, S. K., Godwin, K. M., Cron, S. G., Kelley, C. P., Hersch, G., & Davis, S. (2014). Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial. Disability and Rehabilitation, 36(1), 55-62.

Reason for Exclusion: Not cognitive rehabilitation.

Van de Ven, R., Schmand, B., Groet, E., Veltman, D.J., & Murrem J.M.J. (2015). The effect of computer-based cognitive flexibilityThe ability to shift between different thoughts and actions so that when a problem arises, one can draw upon past mistakes and successes and use this knowledge to plan solutions (Anderson, 2008)
training on recovery of executive function after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.: rationale, design and methods of the TAPASS study. BMC Neurology, 15, 144.

Reason for Exclusion: Study protocol proposal without results.

Rand, D., Eng, J.J., Liu-Ambrose, T., & Tawashy, A.E. (2010). Feasibility of a 6-month exercise and recreation program to improve executive functioning and memory of individuals with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Neurorehabilitation and Neural Repair, 24(8), 722-9.

Westerberg, H., Jacobaeus, H., Hirvikoski, T., Clevberger, P., Östensson, M. L., Bartfai, A., & Klingberg, T. (2007). Computerized working memoryExecutive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously) (Van der Linden, 2007)
training after stroke–a pilot study. Brain Injury, 21(1), 21-29.

Reason for Exclusion: Executive functions training, refer to executive function interventions module.

Zagavec, B. S., Lesnik, V.M., & Goljar, N. (2015). Training of selective attention in work-active strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients. International Journal of Rehabilitation Research, 38, 370-2.

Zedlitz, A.M.E.E., Rietveld, T.C.M., Geurts, A.C., & Fasotti, L. (2012). Cognitive and graded activity training can alleviate persistent fatigue after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., 43, 1046-51.

Reason for Exclusion: Both study groups received cognitive rehabilitation.