What was the aim of this review?
The aim of this Cochrane Review was to find out if occupational therapy improves function in everyday activities and cognition after a stroke. Cognition is the information-processing carried out by the brain such as thinking, paying attention to things you see or hear, learning, remembering, and solving problems. Cochrane researchers collected and analysed all relevant studies to answer this question and found 24 studies.
Key messages
For people with cognition problems after a stroke, occupational therapy may make little to no meaningful difference in the person's ability to do self-care activities, such as showering and dressing, immediately after occupational therapy and six months later. Occupational therapy may improve these people's general information-processing skills and ability to pay attention while looking at something, immediately after the intervention. Occupational therapy may slightly improve some aspects of memory and ability to think flexibly.
The quality of the evidence means that our findings are mostly of low or very low certainty. More well-designed studies that test occupational therapy interventions for cognitive impairment after a stroke are needed.
What did the review study?
Problems with cognition are common after stroke and can affect a person's ability to do everyday self-care activities such as dressing, feeding, and showering, as well as activities in the home or community, such as housework or grocery shopping.
People who have had a stroke can receive a range of therapies after a stroke in hospital, a rehabilitation centre, or in their home. Occupational therapy is one of these therapies. Occupational therapists work with people who have problems with cognition after a stroke to assist them to become as independent as possible. They do this by teaching people ways to adapt to or compensate for the problems, or with training activities to improve cognition (such as memory training), or a combination of these.
What were the main results of the review?
The review authors found 24 relevant studies from 11 countries. These studies compared occupational therapy with a control group that received usual rehabilitation care for people with problems in cognition following stroke. In most studies, the occupational therapy intervention involved training using a computer that had specially designed games to improve cognition. Some interventions involved training in daily activities, such as dressing.
The review showed that when people with cognitive problems after stroke receive occupational therapy, compared to usual care, it may:
– make little to no meaningful difference in their ability to do self-care activities after receiving the therapy and little meaningful difference six months later (low-certainty evidence);
– slightly improve their overall information-processing ability after receiving the therapy (low-certainty evidence);
– result in little to no meaningful difference in their overall ability to pay attention (low-certainty evidence), but likely slightly improves their ability to pay attention to things they see, after receiving therapy (moderate-certainty evidence);
– slightly improve their working memory (low-certainty evidence), but may make little to no difference in other aspects of memory, after receiving the therapy;
– increase slightly their ability to think flexibly after receiving therapy (low-certainty evidence).
The evidence is very uncertain about the effect of occupational therapy on ability to do activities in the home and community, and 'higher-level' information-processing skills that co-ordinate and control other cognitive skills.
There was insufficient evidence of an effect on ability to do self-care activities three months after receiving the therapy and on getting back into community activities.
How up-to-date is this review?
The review authors searched for studies published up to September 2020.
The effectiveness of occupational therapy for cognitive impairment poststroke remains unclear. Occupational therapy may result in little to no clinical difference in BADL immediately after intervention and at three and six months' follow-up. Occupational therapy may slightly improve global cognitive performance of a clinically important difference immediately after intervention, likely improves sustained visual attention slightly, and may slightly increase working memory and flexible thinking after intervention. There is evidence of low or very low certainty or insufficient evidence for effect on other cognitive domains, IADL, and community integration and participation.
Given the low certainty of much of the evidence in our review, more research is needed to support or refute the effectiveness of occupational therapy for cognitive impairment after stroke. Future trials need improved methodology to address issues including risk of bias and to better report the outcome measures and interventions used.
Cognitive impairment is a frequent consequence of stroke and can impact on a person's ability to perform everyday activities. Occupational therapists use a range of interventions when working with people who have cognitive impairment poststroke. This is an update of a Cochrane Review published in 2010.
To assess the impact of occupational therapy on activities of daily living (ADL), both basic and instrumental, global cognitive function, and specific cognitive abilities in people who have cognitive impairment following a stroke.
We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, four other databases (all last searched September 2020), trial registries, and reference lists.
We included randomised and quasi-randomised controlled trials that evaluated an intervention for adults with clinically defined stroke and confirmed cognitive impairment. The intervention needed either to be provided by an occupational therapist or considered within the scope of occupational therapy practice as defined in the review. We excluded studies focusing on apraxia or perceptual impairments or virtual reality interventions as these are covered by other Cochrane Reviews. The primary outcome was basic activities of daily living (BADL) such as dressing, feeding, and bathing. Secondary outcomes were instrumental ADL (IADL) (e.g. shopping and meal preparation), community integration and participation, global cognitive function and specific cognitive abilities (including attention, memory, executive function, or a combination of these), and subdomains of these abilities. We included both observed and self-reported outcome measures.
Two review authors independently selected studies that met the inclusion criteria, extracted data, and assessed the certainty of the evidence. A third review author moderated disagreements if consensus was not reached. We contacted trial authors for additional information and data, where available. We assessed the certainty of key outcomes using GRADE.
We included 24 trials from 11 countries involving 1142 (analysed) participants (two weeks to eight years since stroke onset). This update includes 23 new trials in addition to the one study included in the previous version. Most were parallel randomised controlled trials except for one cross-over trial and one with a two-by-two factorial design. Most studies had sample sizes under 50 participants. Twenty studies involved a remediation approach to cognitive rehabilitation, particularly using computer-based interventions. The other four involved a compensatory and adaptive approach. The length of interventions ranged from 10 days to 18 weeks, with a mean total length of 19 hours. Control groups mostly received usual rehabilitation or occupational therapy care, with a few receiving an attention control that was comparable to usual care; two had no intervention (i.e. a waiting list). Apart from high risk of performance bias for all but one of the studies, the risk of bias for other aspects was mostly low or unclear.
For the primary outcome of BADL, meta-analysis found a small effect on completion of the intervention with a mean difference (MD) of 2.26 on the Functional Independence Measure (FIM) (95% confidence interval (CI) 0.17 to 4.22; P = 0.03, I2 = 0%; 6 studies, 336 participants; low-certainty evidence). Therefore, on average, BADL improved by 2.26 points on the FIM that ranges from 18 (total assist) to 126 (complete independence). On follow-up, there was insufficient evidence of an effect at three months (MD 10.00, 95% CI −0.54 to 20.55; P = 0.06, I2 = 53%; 2 studies, 73 participants; low-certainty evidence), but evidence of an effect at six months (MD 11.38, 95% CI 1.62 to 21.14, I2 = 12%; 2 studies, 73 participants; low-certainty evidence). These differences are below 22 points which is the established minimal clinically important difference (MCID) for the FIM for people with stroke.
For IADL, the evidence is very uncertain about an effect (standardised mean difference (SMD) 0.94, 95% CI 0.41 to 1.47; P = 0.0005, I2 = 98%; 2 studies, 88 participants). For community integration, we found insufficient evidence of an effect (SMD 0.09, 95% CI −0.35 to 0.54; P = 0.68, I2 = 0%; 2 studies, 78 participants). There was an improvement of clinical importance in global cognitive functional performance after the intervention (SMD 0.35, 95% CI 0.16 to 0.54; P = 0.0004, I2 = 0%; 9 studies, 432 participants; low-certainty evidence), equating to 1.63 points on the Montreal Cognitive Assessment (MoCA) (95% CI 0.75 to 2.52), which exceeds the anchor-based MCID of the MoCA for stroke rehabilitation patients of 1.22. We found some effect for attention overall (SMD −0.31, 95% CI −0.47 to −0.15; P = 0.0002, I2 = 20%; 13 studies, 620 participants; low-certainty evidence), equating to a difference of 17.31 seconds (95% CI 8.38 to 26.24), and for executive functional performance overall (SMD 0.49, 95% CI 0.31 to 0.66; P < 0.00001, I2 = 74%; 11 studies, 550 participants; very low-certainty evidence), equating to 1.41 points on the Frontal Assessment Battery (range: 0–18). Of the cognitive subdomains, we found evidence of effect of possible clinical importance, immediately after intervention, for sustained visual attention (moderate certainty) equating to 15.63 seconds, for working memory (low certainty) equating to 59.9 seconds, and thinking flexibly (low certainty), compared to control.