3. Cognitive Rehabilitation for Individuals with Stroke

Notes

Evidence supporting rehabilitation for cognitive challenges related to vascular cognitive impairment (VCI) is growing, but current evidence is in general derived from investigations with a limited number of patient groups, including stroke, acquired brain injury (ABI), mild cognitive impairment (MCI) or mixed dementia. Studies with these mixed populations were included if they specified inclusion of individuals with a vascular etiology.
Overall, specific cognitive interventions fall into two broad approaches, emphasizing either teaching compensation strategies or providing direct remediation and cognitive skill training.
- Compensation focuses on teaching strategies, behaviours and/or external tool use to manage impairments and is often directed at specific activity limitations to promote independence. It can include changes in the physical and social environment or changing the way one performs an activity.
- Direct remediation focuses on providing intensive specific cognitive skill training to directly improve the impaired cognitive domain, with the goal of generalization or transfer of benefits to those activities that rely on that domain. It can include therapist-directed adaptive exercises, usually via computer or tablet-based tools directed at specific deficits.
- Note that commercial brain games are not included in these recommendations. Evidence for functional benefit or impact on activity and participation limitations is limited and requires more research before being integrated into these guidelines.

Refer to the CSBPR7 Vascular Cognitive Impairment module for additional information on assessment, management and rehabilitation for individuals with vascular cognitive impairment. ⁶⁷

Recommendations and/or Clinical Considerations

3.0 Cognitive Rehabilitation for Individuals with Stroke

Individuals presenting with stroke or TIA should be screened for any changes in cognition following stroke compared to their pre-stroke cognitive status. [Strong recommendation; Moderate quality of evidence]. Note, changes can be reported by the individual, family members, caregivers or clinicians. Refer to the CSBPR7 Vascular Cognitive Impairment module Appendix Three for additional information on the presenting signs and symptoms of VCI. ⁶⁷
All individuals with stroke should be assessed to determine their need for cognitive rehabilitation using validated assessment tools where available [Strong recommendation; Low quality of evidence].
Individuals with stroke and cognitive impairments, their family and caregivers should be engaged in the development of a cognitive rehabilitation treatment plan that addresses current impairments and limitations, is goal-oriented and involves shared decision-making [Strong recommendation; Low quality of evidence].
1. Cognitive rehabilitation treatment plans should consider the evolving nature of VCI and be regularly reviewed and adapted as the individual’s cognitive status changes [Strong recommendation; Low quality of evidence].
2. Interventions should be individualized, based on best available evidence, and have the long-term aim to facilitate resumption or continued safe participation of desired activities (e.g., self-care, home and financial management, leisure, driving, return to work) [Strong recommendation; Low quality of evidence].
3. Interventions should consider pharmacological and non-pharmacological approaches [Strong recommendation; Low quality of evidence].
The healthcare team should use a multipronged approach for cognitive rehabilitation that includes both domain specific (e.g. attention, memory, executive function) and global strategies (e.g., physical activity and exercise) [Strong recommendation; High quality of evidence].
Individuals with stroke and VCI who also have communication limitations should be assessed for cognitive rehabilitation using appropriate validated methods particularly for individuals with aphasia [Strong recommendation; Moderate quality of Evidence].

Section 3.0 Clinical Considerations

A comprehensive assessment of cognitive strengths and weaknesses is required to consider the impact of challenges (such as impaired visuo-perceptual function, learning abilities, awareness, and insight of changes) on motivation, ability to engage in planning and treatment, and specific approaches to treatment delivery.
For treatment planning, consider the prognosis for cognitive recovery or decline, and the potential impact of other effects of stroke and existing co-morbidities (such as fatigue, pain, depression/ or anxiety) on the individual’s ability to participate in and benefit from cognitive rehabilitation.
When engaging individuals with VCI, their family and caregivers in cognitive rehabilitation treatment, consider:
1. Interactive education about cognitive strengths and weaknesses, and implications for treatment, function, safety as well as prognosis.
2. The prognosis for cognitive recovery or decline that may impact treatment planning and delivery (e.g., related to the time post stroke, severity of vascular pathology).
3. The availability of social support and the existing physical environment may impact participation, safety, and outcomes. Modifying the social and/or physical environment and embedding structure and routine may be considered to optimize specific cognitive rehabilitation techniques.
Both compensatory and remediation approaches may be applied in a person-centred approach to optimize function.
In addition to interventions tailored for specific cognitive domains, other approaches that directly impact brain function or health (e.g., non-invasive brain stimulation, physical activity) have received growing attention as modulators of cognition.
Multimodal approaches (e.g. diet, social activities, music, health education) may be considered to improve cognitive performance or to prevent cognitive decline.
Virtual reality has been studied to address post-stroke attention, memory and executive function impairments and may be considered, but its efficacy has not been established (further research is required).
Computer based interventions may be considered as an adjunct to clinician-guided treatment. Research in this area continues to evolve rapidly.
Evidence for the impact and outcomes of treatment on activity or participation limitations is limited and requires more research.

3.1 Executive Function

Note: This section includes interventions for the cognitive domain of executive function (planning, organization, self-monitoring and awareness). In most cases this should be considered for mild to moderate executive dysfunction.

Cognitive rehabilitation that focuses on executive function deficits may be addressed with both compensatory and remediation strategies that are appropriate to the individual’s needs and clinical profile [Strong recommendation; Low quality of evidence].
Compensation strategies may include:
1. Metacognitive strategy training and formal problem-solving strategies, under the supervision of a trained therapist, should be considered for individuals with mild to moderate cognitive deficits [Strong recommendation; Moderate quality of evidence].
2. In individuals with reduced self-awareness, the use of skill-specific training and explicit feedback may be considered to promote performance of specifically trained functional tasks [Strong recommendation; Low quality of evidence].
3. Modifications to the environment and external strategies (e.g., written or electronic cues), should be considered for those individuals with mild to severe executive dysfunction [Strong recommendation; Low quality of evidence].
Remediation using targeted computer-assisted executive skill training facilitated and guided by a therapist may be considered [Strong recommendation; Low quality of evidence].

3.2 Attention

Note: This section includes interventions for the cognitive domain of attention (e.g., vigilance, working memory). In most cases this should be considered for mild to moderate attention deficits.

Cognitive rehabilitation that focuses on attention deficits may be addressed with both compensatory and remediation strategies as appropriate to the individual’s needs and clinical profile [Strong recommendation; Low quality of evidence].
Compensation: Modifications of cognitive demands by adapting the environment, tasks or treatment sessions (e.g., duration, planned rests, reducing distractions) may be considered [Strong recommendation; Low quality of evidence].
Remediation: Targeted cognitive training directed by a therapist, such as time pressure management, attention process training or computer-assisted cognitive rehabilitation may be considered for appropriate individuals [Strong recommendation; Low quality of evidence].
1. Working memory deficits may be remediated using targeted computerized working memory skill training facilitated and guided by a therapist [Strong recommendation; Moderate quality of evidence].

3.3 Memory

Compensation strategies may be considered for individuals with stroke and memory difficulties or impairments including:
1. Using strategies that provide external cues or support (e.g. assistive electronic and non-electronic devices) [Strong recommendation; Moderate quality of evidence].
2. Using internal strategies, for those with mild memory difficulties or impairments. These strategies are taught to the individual and could include strategies to increase memorability (e.g., visual imagery, association, and semantic organization) and training techniques (e.g., self-efficacy training, and spaced retrieval practice) [Strong recommendation; Moderate quality of evidence].
3. For those with moderate to severe memory impairments, errorless learning applied to specific functional tasks (e.g., preventing mistakes in repeated practice with cues that are reduced as learning is successful) is recommended as an additional training technique [Strong recommendation; Moderate quality of evidence].

Section 3.3 Clinical Considerations

Treatment for memory difficulties or impairments may be provided individually or in a group setting.

3.4 Aerobic Exercise

Aerobic exercise should be considered where appropriate as a modality to improve attention, working memory and executive function [Strong recommendation; Moderate quality of evidence]. Refer to CSBPR Rehabilitation, Recovery and community Participation Part Two, Section 4.4 for additional information on aerobic training.
Multimodal approaches: Aerobic exercise may be combined with cognitive rehabilitation training to improve attention, working memory and executive function in individuals with VCI [Strong recommendation; High quality of evidence]. Refer to CSBPR Rehabilitation, Recovery and community Participation Part Two, Section 4.4 for additional information on aerobic training.

Rationale +-

Vascular cognitive impairment (VCI) is a frequent consequence of stroke, affecting mental processes such as memory, attention, problem-solving, and executive function. These cognitive challenges can impede an individual's ability to plan daily activities, follow conversations, and make decisions, significantly impacting their independence and quality of life. Many individuals with stroke experience frustration and anxiety due to these cognitive deficits, which can lead to social withdrawal and reduced participation in rehabilitation. Vascular cognitive impairment can complicate recovery, as it can hinder engagement in therapy, ability to follow rehabilitation plans, and the adoption of healthy lifestyle changes.

Individuals with stroke highlight the importance of equitable access to cognitive rehabilitation. They emphasize that individuals with VCI, their family and caregivers should be actively engaged in the development of cognitive rehabilitation treatment plans that are individualized and focus on person-centred goals. Both remedial and compensatory approaches to cognitive rehabilitation are important and helpful to individuals with stroke. Early education focused on awareness of potential cognitive changes following stroke is also highlighted as helpful amongst individuals with stroke. Cognitive challenges may vary depending on setting (e.g., inpatient rehabilitation versus transitioning back into the community), and being aware of what to look for and share back with the healthcare team for further assessment and management is valuable.

Performance Measures +-

System Indicators

Number of inpatient and community-based stroke rehabilitation programs that offer cognitive rehabilitation for primary cognitive deficits.
Proportion of virtual care coverage to remote communities to support organized stroke care across the continuum, including providing cognitive rehabilitation assessments and therapies for individuals with stroke.
Proportion of individuals with stroke who experience new or worsening cognitive symptoms following stroke.

Process Indicators

Proportion of individuals with stroke screened for cognitive impairment.
Proportion of individuals with post-stroke cognitive impairment who undergo an initial cognitive rehabilitation assessment following diagnosis during inpatient admission or entry into a community-based rehabilitation program.
Proportion of individuals with post-stroke cognitive impairment who receive a referral for inpatient or outpatient cognitive rehabilitation (either facility-based or community- based programs).
Median length of time between referral for cognitive rehabilitation to commencement of cognitive rehabilitation therapy.

Patient-Oriented Indicators

Self-reported quality of life following diagnosis of post-stroke cognitive impairment using a validated measurement tool, measured longitudinally.
Functional outcome scores following diagnosis of post-stroke cognitive impairment, measured longitudinally.

Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers

Summary of the Evidence +-

Evidence Table and Reference List 3

Cognitive Rehabilitation

The incidence of post-stroke cognitive impairment during the first year following stroke is estimated at 38% ⁶⁸ but may be affected by factors such as pre-stroke cognition, stroke severity, stroke type, and assessment method. Cognitive rehabilitation interventions typically focus on common deficits of attention, memory or executive function. In general, interventions may be considered to have one of two objectives: 1) to reinforce or re-establish previous behavioural skills or function (e.g., to remediate with computerized exercises) or 2) to teach compensatory mechanisms (e.g., strategy training) that may be either internal or external to the individual. ⁶⁹

In a systematic review including the results of 64 RCTs, including 4,005 individuals with/without cognitive impairment following stroke, trials compared cognitive rehabilitation strategies to improve cognitive function with a control group. ⁷⁰ In 21 studies, multiple component interventions were assessed and included physical activity, lifestyle modifications, rhythm and music therapy, patient and family member education, gait training, computer assisted rehabilitation training, acupuncture, sensory training, and aerobic exercise, among others. Multiple component interventions were associated with higher mean Montreal Cognitive Assessment (MoCA) scores, in patients who had sustained a stroke ≤3 months previously (MD=1.56, 95% CI, 0.69 to 2.43), improved measures of memory, (SMD=0.49, 95% CI, 0.27 to 0.72), and better functional status (SMD= 0.33, 95% CI, 0.05–0.62), compared with individuals receiving standard care. There were no significant differences between groups comparing traditional cognitive rehabilitation interventions with a standard control group in any of the outcomes assessed (general cognitive functioning, memory, executive function, or attention), nor was there a difference between groups comparing cognitive rehabilitation interventions vs. wait list control (memory). Rogers et al. ⁷¹ included the results of 22 RCTs including 1,098 persons with cognitive deficits following stroke. Trials compared cognitive remediation strategies vs. treatment as usual, placebo, or a waitlist control. Types of interventions included computer training (n=8), therapist led interventions (n=7), pen/paper or workbook (n=3), and group therapy (n=4). Overall, cognitive rehabilitation was associated with a small overall effect (Hedges’ g=0.48, 95% CI 0.35–0.60). Domains in which cognitive rehabilitation had the greatest impacts were visio-spatial (Hedges’ g= 0.75, 95% CI 0.18-1.31) and language (Hedges’ g=0.66, 95% CI 0.35-0.96).

Rehabilitation of executive function

Evidence for the effectiveness of the rehabilitation of executive function and problem solving is less compelling. Rozental-Iluz et al. ⁷² reported no significant differences between groups in mean scores of The Executive Function Performance Test following 3 months of participation in an interactive video-game group intervention, compared with persons randomized to a traditional group intervention for motor recovery at least 6 months post stroke. A Cochrane review ⁷³ included the results of 19 RCTs of persons with stroke and other acquired brain injuries. Thirteen trials examined strategies restoring components of executive function (restorative and compensative interventions). No significant treatment effects were reported with respect to concept formation, planning, flexibility, working memory, or extended ADLs between intervention and control groups. Poulin et al. ⁷⁴ included 10 studies examining cognitive rehabilitation strategies to remediate executive function impairments. Nine studies examined an intervention provided during the chronic phase of care. The authors concluded that there is limited evidence to suggest that problem-solving strategies and paging systems are associated with significant improvement in performance on functional tasks that involve executive control, compared to no treatment.

Rehabilitation of attention deficits

A Cochrane review ⁷⁵ included the results of 6 RCTs evaluating interventions designed to either restore attentional functions or provide compensatory strategies for persons with attention deficits post stroke that were provided for 3 to 11 weeks. At the end of the treatment period, cognitive rehabilitation was not associated with significantly greater improvement in measures of subjective reports of global attention (SMD=0.53, 95% CI -0.03 to 1.08, p=0.06), or with significant long-term improvements (>3 months following the end of treatment) on global attention functions (SMD= 0.16, 95% CI -0.23 to 0.56, p=0.41). In no trials were objective measures of global attention reported, either immediately after treatment, or long-term. Cognitive rehabilitation was associated with significantly greater improvement on divided attention, measured using the Paced Auditory Serial Addition Test (SMD= 0.67, 95% CI 0.35 to 0.98, p<0.001). There were no significant effects on other domains of attention associated with cognitive rehabilitation.

Rehabilitation of memory deficits

In a Cochrane review, das Nair et al. ⁷⁶ included the results of 13 RCTs (n=514) examining various memory rehabilitation strategies in persons with memory problems following stroke. Interventions included computerized memory training, strategy training, the use of external memory aides and imagery mnemonics. Memory training was associated with significant improvements in short-term subjective memory measures (SMD= 0.36, 95% CI 0.08-0.64, p=0.01), but not objective memory measures. Training was also not associated with long-term effects of either subjective or objective memory measures, assessed 3-7 months following treatment. Memory self-efficacy training was reported to improve subjective daily memory reports and quality of life in one RCT with 153 stroke patients in the chronic phase of stroke, ⁷⁷ with benefits persisting at 6 and 14 months. ⁷⁸

Physical activity

Physical activity may also be beneficial for the rehabilitation of cognitive impairment post stroke. Oberlin et al. ⁷⁹ included the results of 14 RCTs and reported a small to moderate mean effect size (Hedges’ g =0.304, 95% CI 0.14–0.47, p<0.001). Cumming et al. ⁸⁰ included 9 trials investigating the effect of exercise on cognition in stroke patients, also reported a significant, but small, pooled treatment effect (SMD= 0.2, 95%, CI 0.04 to 0.36, p=0.015).

Virtual reality (VR)

Zang et al. ⁸¹ included 23 RCTs including 894 patients recovering from stroke. Participants in these trials were randomized to receive usual care or VR-based interventions (single, or multiple-component interventions) using a screen or a head-mounted device, including games with immersive, semi-immersive, and non-immersive systems, simulating virtual environments. Interventions were provided for an average of 4 weeks (2-5x/week). VR interventions were not associated with significant improvements in global cognition or attention but were associated with significant improvements in executive function (SMD=0.88, 95% CI 0.6 to 1.70), and memory (SMD=1.44, 95% CI 0.21 to 2.68).

Computer-based training

Two recent systematic reviews examined outcomes in cognitive function following rehabilitation using commercially available computer assisted cognitive rehabilitation. Mingming et al. ⁸² included the results from 10 RCTs including 600 adults with post-stroke cognitive impairments. Participants were randomized to receive computer-based cognitive training (CBCT), using commercially available systems (e.g., RehaCom) or usual cognitive rehabilitation. The duration of therapy ranged from 7 to 60 hours. The training dose and frequency in most studies was 30 min per session with 5 sessions per week. Pooling the results from 6 trials, CBCT was not associated with significant improvement in overall cognition (SMD=0.59, 95% CI -0.06 to 1.24). In contrast, Nie et al. ⁸³ included 32 RCTs in which 1,837 participants, were also randomized to receive computer-assisted cognitive rehabilitation (CACR) using commercially available systems or usual cognitive rehabilitation. CACR was associated with significant improvement in MoCA scores (MD= 2.67, 95% CI 2.21 to 3.13), Mini Mental State Examination scores (MD= 2.51, 95% CI 1.94 to 3.08), Loewenstein Occupational Therapy Cognitive Assessment scores (MD= 8.63, 95% CI 4.99 to 12.28) and Functional Independence Measure and Barthel Index scores at the end of treatment.

Sex & gender considerations

Exalto et al. ⁸⁴ reported an equal percentage of men and women experienced post-stroke cognitive impairment, (51%), when assessed within 15 months of stroke; however, there were sex differences within the cognitive domains. Compared with women, men had lower odds of impairment of attention and execute function (24% lower) and language (33% lower), while their odds of verbal memory impairment were 43% higher. There were no significant differences between the sexes in information processing speed, language, visuospatial perception/construction, and visuospatial memory. No sex & gender differences were found with respect to response to interventions for cognitive rehabilitation.