Is occupational therapy helpful for cognitive impairment in stroke patients?

Four out of ten patients present cognitive impairment one year after a stroke. Cognitive impairments involve multiple functions of the brain including obtaining, elaborating and using the information to develop thought and conduct behaviour. An impaired cognition correlates with lower functional independence, higher mortality, depression, institutionalisation, and poor social and community participation. In this scenario, occupational therapy plays the main role in managing cognitive impairment, aiming to enhance the functional independence of basic activities of daily living (BADL) and of instrumental activities of daily living (IADL) and to increase social participation.

This review investigated whether, compared to usual care, occupational therapy may be helpful for people with post-stroke cognitive impairment to improve their functional independence in activities of daily living (ADL) and to improve global and specific cognitive functions.

This review is important for

People with post-stroke cognitive impairment, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

Outcomes of this review

This is an update of a Cochrane Systematic Review (CSR) published in 2010. The outcomes analysed were BADL and IADL, measures of independence and activities; community integration and participation; global cognitive function; and specific cognitive abilities.

The CSR included 24 trials published and/or registered up to September 2020, with 1,142 adult participants.

Results showed that occupational therapy compared to usual care may make little or no difference in self-care after therapy and little difference following six months. It may slightly improve information processing after therapy, yet produce little to no difference in overall attention; whereas, it is likely to slightly improve visual attention. Occupational therapy may slightly improve working memory only; whereas, for other elements of memory it may produce little or no difference after therapy. It may slightly increase thinking flexibility. Furthermore, the authors were uncertain whether occupational therapy improves the ability to carry on activities in-home or in the community, and whether it improves higher cognitive skills. Evidence was lacking to assess the effect of therapy on the ability to carry on self-care and community activities after three months.

These results must be interpreted with caution because some trials (i) did not report a sufficiently detailed description of the intervention or the control; and (ii) the role of the therapist was not plainly explained, thus limiting reproducibility. (iii) A description of the rationale was lacking for many interventions. (iv) The outcomes measures were variable. (v) Patient’s characteristics such as stroke severity and overall physical status were not adequately described. (vi) For some outcomes there was concern about imprecision due to insufficient sample sizes, and (vii) inconsistency due to substantial heterogeneity.

Author’s conclusion of the review

There is unclear evidence for the benefits of occupational therapy for people affected by cognitive impairment after stroke. Occupational therapy may lead to no or little clinical improvement in BADL after therapy and after three or six months of follow-up. Occupational therapy may slightly improve global cognitive performance after therapy; it is likely to slightly improve visual attention, and it may slightly increase working memory and flexible thinking after the intervention. It is insufficient to low-certainty evidence for an improvement in other aspects of cognition, IADL, and community integration and participation.

Future recommendations

The authors recommended that further high-quality studies are needed, particularly to find out (a) the most effective elements of combined occupational therapy approaches and (b) which specific approach is the most appropriate individually. Furthermore, these studies should assess (c) the optimal length of intervention and (d) the long-term effects on the outcomes analysed.  Future research also should try to minimize (e) selection and performance bias as well as blinding bias, even if the latter could be challenging for the nature of the intervention.

Robin Kuruvila Sentinella