CENTENNIAL VISION
Rehabilitation, Disability, and Participation Research:
Are Occupational Therapy Researchers Addressing
Cognitive Rehabilitation After Stroke?
ONLINE ONLY
Timothy J. Wolf
KEY WORDS
activities of daily living
cognition disorders
rehabilitation
review
stroke
treatment outcome
I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to
assess (1) whether research was published in the practice area of rehabilitation, disability, and participation and
(2) the evidence being produced in an underdeveloped subcategory of this practice area: cognitive rehabilitation after stroke. The review revealed one intervention effectiveness study that addressed cognitive rehabilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence
in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive
dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive
intervention approaches in use have been shown to have little or no effect on improving everyday life activity.
Occupational therapy has a key research and practice role with the poststroke population, and occupational
therapists should be at the forefront in developing the science to support the effectiveness of their services.
Wolf, T. J. (2011). Centennial Vision—Rehabilitation, disability, and participation research: Are occupational therapy
researchers addressing cognitive rehabilitation after stroke? American Journal of Occupational Therapy, 65, e46–
e59. doi: 10.5014/ajot.2011.002089
Timothy J. Wolf, OTD, MSCI, OTR/L, is Assistant
Professor, Program in Occupational Therapy and
Department of Neurology, Washington University School
of Medicine, St. Louis, MO 63108; [email protected]
e46
A
key component of the American
Occupational Therapy Association’s
(AOTA’s) Centennial Vision is the desire
to be an “evidence-based profession” by
2017 (AOTA, 2007). This desire is not
unique to occupational therapy and is, in
fact, a major focus of the national health
care community. The U.S. Congress
asked the Institute of Medicine to establish a list of comparative effectiveness research questions that need to be answered
to improve health care quality for all
Americans (Committee on Comparative
Effectiveness Research Prioritization,
Board on Health Care Services, 2009). If,
as a profession, occupational therapy is to
meet the goal of being evidence based, the
occupational therapy scientific community must place a concentrated effort on
conducting comparative effectiveness
studies to produce evidence to support
practice. Although most of this work falls
on the occupational therapy scientific community, success in achieving the goal to be
evidence based will also require each occupational therapy practitioner to contribute
his or her part. The production of evidence
to support occupational therapy services is
only truly effective when practitioners integrate evidence into their practice. The role
that the American Journal of Occupational
Therapy (AJOT) plays in this process is the
evaluation of the quality of evidence produced in all areas of occupational therapy
practice and the dissemination of this evidence in an effective manner to practitioners.
As part of the development process
related to the Centennial Vision, occupational therapy practice was categorized into
six broad areas of practice: (1) children and
youth; (2) health and wellness; (3) mental
health; (4) productive aging; (5) work and
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industry; and (6) rehabilitation, disability,
and participation. The rehabilitation, disability, and participation category arguably
represents the largest area of occupational
therapy practice; it is focused on helping
people with any illness, injury, or deficit in
occupational performance that is not specified in the other practice areas improve their
participation in everyday life activities. This
practice area includes people with Alzheimer’s disease, traumatic brain injury (TBI),
chronic pain, multiple sclerosis, spinal cord
injury, Parkinson’s disease, and stroke; it also
encompasses driving and community mobility for older adults. This short list involves
some of the largest populations with which
occupational therapists and occupational
therapy assistants work, and it by no means
encompasses all conditions addressed in this
area of practice. The breadth of this practice
area makes it critical to evaluate the research
evidence produced to determine which
populations and practice methods are adequately addressed and which require more
attention. Therefore, the purpose of the review described in this article was twofold: (1)
to summarize and evaluate the rehabilitation,
disability, and participation research published AJOT in 2009 and 2010 and (2) to
synthesize and review the evidence being
produced in an underdeveloped subcategory
of rehabilitation, disability, and participation
practice: cognitive rehabilitation poststroke.
Rehabilitation, Disability, and
Participation Research Published
in AJOT: 2009 and 2010
In 2009 and 2010, AJOT published 58
articles that addressed the practice area
of rehabilitation, disability, and participation: 20 studies (34.5%) were effectiveness studies that evaluated some
form of intervention; 5 studies (8.6%) were
efficiency studies evaluating aspects of
practice other than effectiveness (e.g., cost
and time efficiency, patient satisfaction,
adherence); 16 studies (27.6%) were basic
research examining a specific clinical phenomenon; 15 studies (25.9%) described
instrument development and testing; and 2
studies (3.4%) examined the link between
occupational engagement and health. The
fact that effectiveness studies represented
the largest percentage of the rehabilitation,
disability, and participation literature
published in AJOT in 2009 and 2010 is
a positive sign that occupational therapy
researchers are addressing the goal of being evidence based, given that effectiveness studies are the most critical for
developing evidence.
AJOT uses the following system to
classify effectiveness studies into levels of
evidence (Lieberman & Scheer, 2002):
Level I—systematic reviews, meta-analyses,
and randomized controlled trials; Level II—
two-group, nonrandomized studies (e.g., case
control); Level III—one-group, nonrandomized studies (e.g., pretest–posttest
design); Level IV—descriptive studies (e.g.,
case series design); and Level V—case
reports and expert opinion. Level I is considered the highest level of evidence in this
classification. The 20 effectiveness studies
reviewed for this article are summarized in
Table 1.
Fifteen of the 20 effectiveness studies
were related to either stroke or traumatic
brain injury (TBI). Those related to TBI
(n 5 7) examined a broad spectrum of treatment approaches targeting both impairmentlevel and participation-level outcomes,
including intermittent self-catheterization
(Carver, 2009); problem-solving strategies
(Fong & Howie, 2009); improvement of
learning or memory (Giuffrida, Demery,
Reyes, Lebowitz, & Hanlon, 2009; Goverover,
Arango-Lasprilla, Hillary, Chiaravalloti, &
DeLuca, 2009; Goverover, Chiaravalloti, &
DeLuca, 2010); community reintegration
(Kim & Colantonio, 2010); and improvement of self-care abilities (Zlotnik, Sachs,
Rosenblum, Shpasser, & Josman, 2009).
The effectiveness studies related to stroke
(n 5 8) were much narrower in focus and
targeted primarily upper-extremity dysfunction or motor impairment (Earley,
Herlache, & Skelton, 2010; Hardy et al.,
2010; Hayner, Gibson, & Giles, 2010;
Nilsen, Gillen, & Gordon, 2010; Rowe,
Blanton, & Wolf, 2009) and self-care and
activities of daily living (ADLs; Hermann
et al., 2010; Preissner, 2010). The 2 stroke
self-care studies, although focused on participation (ADLs), also addressed primarily
people with upper-extremity dysfunction
or motor dysfunction poststroke. Only 1
stroke effectiveness study specifically
addressed a different area of impairment
poststroke—cognitive dysfunction (Rand,
Weiss, & Katz, 2009). The remaining effectiveness studies (n 5 5) involved hand
injury (Hall, Lee, Page, Rosenwax, & Lee,
2010; Stapanian, Stapanian, & Staley,
2010), arthritis ( Jack & Estes, 2010), lymphedema (McClure, McClure, Day, &
Brufsky, 2010), and acute care rehabilitation (Thorne, Sauve, Yacoub, & Guitard,
2009). Although collectively, the studies
related to rehabilitation, disability, and
participation published in AJOT during this
period demonstrate that occupational therapy researchers are producing evidence,
some concerns need to be addressed related
to becoming evidence based in this practice
area.
Concerns in Rehabilitation,
Disability, and Participation
Research
Research That Does Not Produce
Evidence for the Profession
Most of the research related to rehabilitation, disability, and participation did
not produce evidence for the profession.
Of the 58 rehabilitation, disability, and
participation studies published in AJOT in
2009 and 2010, 38 were efficiency studies,
basic research studies, instrument development and testing studies, or studies
that explored the link between occupational engagement and health. All four of
these areas serve a key role in the continuum of research and are ultimately necessary for the development of evidence to
support the profession. For example, efficiency studies are necessary to determine
whether a certain intervention can affect an
outcome. It is crucial to conduct a study of
this nature to determine whether an effectiveness study is warranted. For example,
Walker and colleagues (2010) developed
a community mobility skills course for
people using mobility devices. The authors
were able to determine that some skills
gained through a community mobility
skills course can transfer to use in a realworld environment; this finding can now
be translated into clinical guidelines that
can be evaluated in effectiveness studies.
The review of the AJOT literature
reported in this article highlights the fact
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e48
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V
II
II
II
Earley, Herlache, &
Skelton (2010)
Fong & Howie (2009)
Giuffrida, Demery,
Reyes, Lebowitz, &
Hanlon (2009)
Goverover,
Arango-Lasprilla,
Hilary, Chiaravalloti, &
DeLuca (2009)
II
V
Carver (2009)
Goverover, Chiaravalloti, &
DeLuca (2010)
Level of
Evidence
Author/Year
Content Area
Use of self-generated vs.
directed strategies
Cognitive dysfunction
TBI
Use of spacing effect to
improve learning and memory
Cognitive dysfunction
TBI
Effect of different practice
schedules on improving function
Cognitive dysfunction
TBI
Problem-solving treatment
Cognitive dysfunction
ABI
mCIMT
Upper-extremity dysfunction
Stroke
Treatment with assistive
technology
Intermittent
self-catheterization (ISC)
TBI
Patients with TBI
documented by CT or
MRI (n 5 10) and
healthy controls
(n 5 15)
Patients with TBI
documented by CT or MRI
(n 510) and healthy controls
(n 5 15)
Patients with chronic
cognitive impairment after
TBI (n 5 6)
Outpatient rehabilitation
patients in Hong Kong
with moderate ABI (n 5 33)
Chronic stroke patient
4 years post-CVA (n 5 1)
Inpatient rehabilitation
patient with TBI (n 5 1)
Sample
Methods
All groups completed 2 meal
preparation tasks and 2 financial
management tasks. One task for
each condition was completed using
provided instructions, and the other
task was completed using self-generated
instructions.
Case control
All groups completed both a
paragraph and a route-learning task.
Within groups, patients were split into
either spaced or massed learning groups.
Case control
All participants completed 3 tasks:
touch typing, 5- to 6-digit sequence
typing, and subway schedule task.
Patients were assigned to random
practice (n 5 3) or blocked
ordered practice (n 5 3).
Case control
Treatment group (n 5 16) received
additional problem-solving training.
Both groups received cognitive training
program.
RCT with matched pairs (2 groups)
Patient received mCIMT with home
exercise program (4 weeks).
Case study with pre–post assessment
Goal was to improve independence with
ISC through construction and use of splint.
Case study
Impairment
In both groups, better results from
self-generated learning than from directed
learning
No significant difference between TBI and
control groups
Impairment
In both groups, better results from spaced
learning than from massed practice
No significant difference between TBI and
control group
Transfer of learning to another task
demonstrated by random practice group
Impairment
Improvements in all groups from baseline
performance, retained over 2 weeks
Function
No significant differences
Impairment
Improved total score and score on one
subtest of metacomponents and executive
function
Function
Improved self-rating of IADL performance
Impairment
Improved ROM, MMT, pinch/grip
Function
Improved independence with ISC
Outcomes
Table 1. Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
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The American Journal of Occupational Therapy
e49
I
IV
I
V
IV
I
Hall, Lee, Page, Rosenwax,
& Lee (2010)
Hardy et al. (2010)
Hayner, Gibson, &
Giles (2010)
Hermann et al. (2010)
Jack & Estes (2010)
Kim & Colantonio (2010)
Improvement in community
reintegration outcomes
Postacute rehabilitation
intervention
TBI
Evaluation of a different
intervention approach
Lupus related
Arthritis
Telerehabilitation and
task-specific training
ADL limitations
Stroke
CIMT
Upper extremity dysfunction
Stroke
Treatment study combining
2 existing protocols
UE spasticity
Stroke
Comparison of 3 postoperative
treatment protocols
Extensor tendon repair (ETR)
Hand injury
10 research articles from
1990 to 2007 related to
improving community
reintegration post-TBI
Orthopedic outpatient clinic
patient with lupus-related
arthritis (n 5 1)
Community-dwelling patient
with chronic stroke (>3 years
post-CVA; n 5 1)
Community-dwelling people
with chronic stroke
symptoms (>6 months
post-CVA; n 5 12)
Outpatient clinic
patients (n 5 2) with
chronic stroke (>6 months
post-CVA) and documented
UE spasticity
Hospital-based outpatient hand
clinic patients with ETR (n 5 18) with
24 total injured fingers
Goal was to identify evidence to
support postacute rehabilitation
intervention approaches that
address community reintegration.
Seven articles provided this evidence.
Systematic review
Patients received treatment using the
occupational adaptation model.
Case study with pre–post
assessment
Patients were treated with telerehabilitation
protocol to improve
ADLs (4 weeks).
Case study with pre–post assessment
Groups were stratified by more or less
impaired.
Treatment group (n 5 6) received CIMT
protocol.
Control group (n 5 6) received bilateral
treatment protocol.
RCT (2 groups)
Treatment combined UE bracing with
electrical stimulation in a functional
training program.
Case study with pre–post assessment
All participants were assessed
3, 6, and 12 wk posttreatment.
Patients were assigned to
immobilization (n 5 4), early
passive motion (n 5 5), or early
active motion (n 5 9) treatment groups.
RCT (3 groups)
(Continued)
Benefits of postacute
TBI rehabilitation programs to improve
community reintegration supported by 7
of 10 articles
Occupational therapy or occupational
therapy interventions involved in all studies
Function
Improved performance on all functional
tasks addressed in treatment
Function
Improved motor function
Improved self-rating of performance and
satisfaction
Impairment
Improved UE movement
Function
Improved self-rating of performance and
satisfaction in both groups
Therapeutic improvement a factor of
treatment intensity and not related to
protocol followed
Function
Improved motor function
Improvements retained at 3 mo
posttreatment
Impairment
Decreased spasticity
Impairment
Across all time points,
improvement in all groups
Greatest treatment effect
with early active
motion protocol
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e50
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V
III
Preissner (2010)
Rand, Weiss, &
Katz (2009)
IV
I
Nilsen, Gillen, &
Gordon (2010)
Rowe, Blanton, &
Wolf (2009)
I
Level of
Evidence
McClure, McClure, Day, &
Brufsky (2010)
Author/Year
Constraint-induced movement
therapy
UE dysfunction
Stroke
Evaluation of a multitasking
intervention protocol
Cognitive dysfunction
Stroke
Use of the task-oriented
approach to improve ADL
function
Cognitive dysfunction
Stroke
Use of mental practice to
improve recovery
UE dysfunction
Stroke
Evaluation of a recovery
program to improve
physical and emotional
symptoms
Breast cancer–related
lymphedema (BCRL)
Content Area
Community-dwelling person
with chronic stroke (5 yr
post-CVA; n 5 1)
Community-dwelling people
poststroke with executive
function deficits (n 5 4)
Inpatient rehabilitation
setting stroke patient with
motor and cognitive
dysfunction (n 5 1)
15 research articles published
between 1985 and 2009
focused on using mental
practice as part of a stroke
rehabilitation intervention
Community-setting patients
with BCRL recruited from
local hospitals, clinics, and
events (n 5 32)
Sample
Methods
Patients received 2 wk of CIMT
treatment.
Case study with pre–post and
longitudinal assessment
Patients were treated using VMall,
a virtual supermarket, to improve
multitasking.
Pre–post assessment
Patients were treated with the taskoriented approach.
Case study with pre–post assessment
Goal was to determine whether
using mental practice is effective
in improving UE recovery poststroke.
Systematic review
Treatment group (n 5 16) was
treated with breast cancer recovery
program emphasizing exercise and
relaxation. Control group (n 5 16)
received standard care.
RCT (2 groups)
Impairment
Improved motor performance
Function
Improved self-reported function
Improvement retained at 5 years
Impairment
Improvements on performance-based
assessment of executive function
Function
Improved self-care performance
after treatment
Impairment
Support by most articles for
mental practice as effective
in reducing impairment and
improving function of
affected UE
Generalizability of findings
limited by the mostly
heterogeneous study populations
Function
Significantly improved quality of life in
treatment group compared with controls
Impairment
Significantly improved bioimpedance,
flexibility, mood, and weight loss in
treatment group compared with controls
Outcomes
Table 1. Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010 (cont.)
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The American Journal of Occupational Therapy
e51
II
V
Thorne, Sauve, Yacoub,
& Guitard (2009)
Zlotnik, Sachs, Rosenblum,
Shpasser, & Josman (2009)
TBI
Adolescents
Evaluation of the
Dynamic Interaction
Model (DIM) intervention
approach
Evaluation of gel pads used to
decrease pressure sores
Pressure sores
Acute care
Evaluation of treatment
methods used
Bilateral amputation of all
fingers
Hand injury
Inpatient rehabilitation
patients post-TBI (n 5 2)
Heterogeneous sample of
acute care patients at high
risk to develop pressure
sores (n 5 60)
Community-dwelling person
with all fingers amputated
secondary to frostbite (n 5 1)
Patients were treated using the
DIM to improve function post-TBI.
Case study with pre–post
assessment
Interface pressure was evaluated
with and without use of gel pad
in supine position.
Two-group, nonrandomized crossover
Outcomes were evaluated after
index finger residual transfer
to thumb.
Case study with pre–post and
longitudinal assessment
Function
Improved writing, mobility, and
independence in self-care posttreatment
Impairment
No significant difference in pressure with or
without use of the gel pad
Impairment
Improved ROM of thumb MP joint
posttreatment and at follow-up 17 years
posttreatment
Note. ABI 5 acquired brain injury; ADL 5 activity of daily living; CIMT 5 constraint-induced movement therapy; CT 5 computed tomography; CVA 5 cerebrovascular accident; IADL 5 instrumental activity of daily living;
mCIMT 5 modified constraint-induced movement therapy; MMT 5 manual muscle test; MP 5 metacarpophalangeal; MRI 5 magnetic resonance imaging; RCT 5 randomized controlled trial; ROM 5 range of motion; TBI 5
traumatic brain injury; UE 5 upper extremity.
V
Stapanian, Stapanian,
& Staley (2010)
that most research in this area of practice is
in an early phase of development (e.g.,
basic science and efficiency studies) and has
not progressed to the level of effectiveness
studies. This concern is notable for the
profession because effectiveness studies are
the only studies that truly produce evidence. If the occupational therapy profession is to meet the goal of being evidence
based in this practice area, the research
community must give special consideration to developing lines of research inquiry along the research continuum,
culminating in effectiveness studies.
Poor Representation of
Several Populations
Several populations may be poorly represented in the work being produced in
rehabilitation, disability, and participation. Stroke and TBI were overrepresented
in the effectiveness studies reviewed for
this article; however, several considerations
must be noted. First, the results are skewed
by the fact that many of the studies were
published in a 2009 special issue of AJOT
focused on stroke and TBI. Second, although stroke and TBI affect two of the
largest populations with which occupational therapists work, thereby warranting
a special issue to highlight related work
being produced, in the past 2 years the focus on stroke and TBI created a void that
left several other major populations underrepresented in AJOT. For example,
spinal cord injury (SCI) affects a large
population with which occupational therapy practitioners work in a variety of rehabilitation settings. AJOT published no
effectiveness studies in 2009 and 2010 related to the SCI population. AJOT should
give special consideration to the production of special issues highlighting research related to other populations with
whom practitioners work in rehabilitation,
disability, and participation.
Preponderance of Case Studies and
Studies With Small Sample Sizes
Most effectiveness studies related to rehabilitation, disability, and participation
are case studies or have a small sample
size, which limits the generalizability of
the findings. Of the 20 effectiveness studies
e52
published by AJOT in 2009 and 2010 related to rehabilitation, disability, and participation, nearly half (n 5 9) were case
studies (Carver, 2009; Earley et al., 2010;
Hardy et al., 2010; Hermann et al.,
2010; Jack & Estes, 2010; Preissner,
2010; Rowe et al., 2009; Stapanian
et al., 2010; Zlotnik et al., 2009). Moreover, 4 studies had <10 participants per
intervention group evaluated (Giuffrida
et al., 2009; Hall et al., 2010; Hayner et al.,
2010; Rand et al., 2009). This review
suggests that the evidence being published
is not at the strongest levels to support
practice. This finding speaks to a larger issue in occupational therapy research: Sufficiently powered randomized controlled
studies (Level 1 evidence) require many
resources to conduct, and few occupational
therapy scientists have the research infrastructure and resources necessary to
conduct such trials. In addition, the trials
that are being conducted are being reported
in venues other than AJOT. For these reasons, it is critical that the Level I evidence
being produced make its way back to the
occupational therapy community. AJOT
should make the Level I evidence in this
practice area accessible to the occupational
therapy community through systematic
reviews or other avenues such as the AOTA
Evidence-Based Practice and Research
resources.
searchers must highlight this unique contribution to the health care community by
including measures of participation in
studies that demonstrate occupational
therapy’s effectiveness.
Need to Address Poststroke
Cognitive Dysfunction
A significant need exists for occupational
therapy practitioners in rehabilitation,
disability, and participation to expand
their focus to address poststroke cognitive
dysfunction. Among the many areas that
arguably need to be addressed in producing evidence to support occupational
therapy practice in this area, one of the
most critical is cognitive dysfunction after
a stroke. The AOTA Research Advisory
Panel (2009) identified people with cognitive impairments, specifically after stroke,
as a priority population in the Occupational
Therapy Research Agenda. The review undertaken for this article highlighted that although evidence is being produced related
to stroke, most of this work is focused on
motor recovery and self-care. The remainder of this article addresses the unique needs
of people with cognitive dysfunction poststroke, the reasons poststroke cognitive
rehabilitation should be a priority for occupational therapy practitioners, and the
evidence being produced to support practice
in this area.
Outcome Measures at the
Impairment Level
Cognitive Dysfunction
After Stroke
More than half of the rehabilitation, disability, and participation effectiveness
studies reported in AJOT in 2009 and
2010 (n 5 11) used impairment-level measures as their primary outcome measures
(Earley et al., 2010; Fong & Howie, 2009;
Giuffrida et al., 2009; Goverover et al.,
2009, 2010; Hall et al., 2010; McClure
et al., 2010; Nilsen et al., 2010; Rand et al.,
2009; Stapanian et al., 2010; Thorne et al.,
2009). Impairment associated with any
disorder, disease, or condition must be
addressed in some capacity during rehabilitation to improve participation;
however, the unique contribution of occupational therapy practitioners to the health
care community is their focus on everyday
life participation. Occupational therapy re-
People with stroke are one of the largest
groups that occupational therapists serve.
Stroke syndromes are complex and include
a wide variety of symptoms; however,
studies have shown that the functional
scales used to guide intervention after
stroke (e.g., FIMTM, Barthel Index are
biased toward physical disability, given
their high correlation with measures of
motor performance (Hajek, Gagnon, &
Ruderman, 1997). The health care community’s overfocus on physical disability
and ADL performance has led to an underappreciation of other deficits after
stroke that affect everyday life, particularly
cognitive impairment. Cognitive impairment poststroke is prevalent: As many
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as 65% of stroke survivors exhibit some
sort of cognitive dysfunction (Donovan
et al., 2008; Edwards, Hahn, Baum, &
Dromerick, 2006; Rochette et al., 2007;
Wolf, Baum, & Connor, 2009). Even people
with mild neurological impairment after
a stroke who are independent in ADLs
and have limited or no physical impairment can exhibit debilitating cognitive
impairment that lowers their ability to
return to complex activities such as work,
community roles, and driving (Edwards
et al., 2006; Rochette et al., 2007; Wolf
et al., 2009).
In 2009 and 2010, AJOT published
only 1 effectiveness study that specifically
addressed cognitive dysfunction poststroke.
Rand and colleagues (2009) evaluated use
of a virtual supermarket to train clients
in multitasking after stroke (Level III evidence). Even though this area of practice was
underrepresented in AJOT, my review of
outside repositories of stroke research demonstrated that in general, insufficient evidence exists to support this area of practice.
Existing Knowledge of Cognitive
Rehabilitation After Stroke
The second purpose of this review was to
synthesize and review the evidence produced in an underdeveloped subcategory
of rehabilitation, disability, and participation practice: poststroke cognitive rehabilitation. Two of the leading publicly
available repositories of evidence-based
reviews are the Cochrane Reviews (www2.
cochrane.org/reviews) and the EvidenceBased Review of Stroke Rehabilitation
(EBRSR; www.ebrsr.com). The EBRSR is
an excellent resource for evidence to support stroke rehabilitation, but a major
limitation exists in its clinical utility related
to addressing cognitive dysfunction poststroke: Most of the evidence reported in the
EBRSR comes from studies of TBI, not
stroke. Although the clinical presentation
of cognitive dysfunction can sometimes be
similar, the populations are sufficiently
different to warrant further study using the
methodologies reported in the EBRSR to
confirm whether findings can be replicated
with a stroke population. For this reason, I
did not review the EBRSR information
related to cognitive dysfunction. To ex-
amine available evidence to support cognitive rehabilitation poststroke, I examined
the information reported in the Cochrane
Reviews.
Cochrane Reviews
The Cochrane Collaboration is a network
of scholars focused on helping stakeholders
in health care (e.g., policymakers, health
care providers, consumers, caregivers)
make well-informed health care decisions (Mavergames et al., 2010) by systematically reviewing and assessing all
available evidence for specific interventions and populations. Cochrane Reviews are continuously updated to ensure
that reviews provide the most current
information. Three Cochrane Reviews
addressed poststroke cognitive rehabilitation for (1) attention deficits (Lincoln,
Majid, & Weyman, 2000), (2) memory
deficits (das Nair & Lincoln, 2007), and (3)
spatial neglect (Bowen & Lincoln, 2007).
Each group completed a comprehensive
review of electronic databases and hand
searches of journals related to the specific
topic. All three coordinated with the Cochrane Stroke Group, and details of their
search criteria can be found in their references or on the Stroke Group’s Web page
(Editorial Team, Cochrane Stroke Group,
2010). Of particular note, the Stroke
Group used strict inclusion criteria, and
only controlled trials and systematic reviews were included (AJOT Level I only).
Table 2 summarizes the studies identified
by the Cochrane Reviews to support cognitive rehabilitation for attention, memory, and spatial neglect poststroke.
In the Cochrane Review that examined cognitive rehabilitation for attention
deficits after stroke, two trials were identified (Schöttke, 1997; Sturm & Willmes,
1991). The authors of the review concluded that evidence supports the use of
cognitive training to improve alertness and
sustained attention; however, no evidence
has indicated that such improvements
translate to improvement in everyday life
activities (Lincoln et al., 2000).
In the review that examined memory
deficits, two studies were also identified
(see Table 2; Doornhein & deHaan, 1998;
Kaschel et al., 2002). Neither study demon-
strated any significant effect of memory
rehabilitation on impairment-level assessments, and the review group therefore
concluded that no evidence either supports
or refutes the effectiveness of memory rehabilitation on functional outcomes (das
Nair & Lincoln, 2007).
Finally, the group that examined spatial
neglect identified 11 studies that evaluated
the effectiveness of various interventions (see
Table 2; Cherney, Halper, & Papachronis,
2003; Edmans, Webster, & Lincoln,
2000; Fanthome, Lincoln, Drummond, &
Walker, 1995; Kalra, Perez, Gupta, &
Wittink, 1997; Robertson, Gray, Pentland,
& Waite, 1990; Robertson, McMillan,
MacLeod, Edgeworth, & Brock, 2002;
Rossi, Kheyfets, & Reding, 1990; Rusconi,
Meinecke, Sbrissa, & Bernardini, 2002;
Weinberg et al., 1977; Wiart et al., 1997;
Zeloni, Farne, & Baccini, 2002). Again,
the group concluded that although some
evidence has supported the effectiveness of
the interventions in improving performance on impairment-level testing, insufficient evidence exists to support or
refute the effectiveness of any of the intervention approaches in reducing disability
and improving independence in everyday
life activities (Bowen & Lincoln, 2007).
The available data from the Cochrane
Reviews clearly indicate that insufficient
knowledge and evidence are being produced by occupational therapy—or any
other health care profession—to support or
refute the effectiveness of cognitive rehabilitation approaches poststroke. Moreover, none of the studies in the three
reviews demonstrated that any of the intervention approaches translated to improvement in everyday life activities—
a clinical objective within occupational
therapy’s domain. Note that a Cochrane
Review protocol was published indicating
intent to produce a review related to
occupational therapy’s effectiveness in
improving function in people with cognitive impairment poststroke (Hoffmann,
Bennett, Koh, & McKenna, 2007).
The Cochrane Reviews demonstrate
that limited evidence is being produced
anywhere by any health care profession to
support specific cognitive intervention approaches that can improve everyday life
performance after a stroke. This situation is
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July/August 2011, Volume 65, Number 4
“Two approaches to treating
unilateral neglect after right
hemisphere stroke: A preliminary
investigation” (Cherney, Halper, &
Papachronis, 2003)
“Cognitive rehabilitation for
spatial neglect following
stroke” (Bowen & Lincoln,
2007)
“Imagery mnemonics for the
rehabilitation of memory: A
randomised group controlled trial”
(Kaschel et al., 2002)
Speech language
pathology, physical
medicine and
rehabilitation
Neuropsychology
Neuropsychology
“Cognitive rehabilitation for
memory deficits following stroke”
(das Nair & Lincoln, 2007)
“Cognitive training for memory
deficits in stroke patients”
(Doornhein & deHaan, 1998)
Neuropsychology
Neuropsychology
Profession
“Efficacy of a reaction
training on various
attentional and cognitive
functions in stroke
patients” (Sturm & Willmes,
1991)
“Rehabilitation von
Aufmerksamkeits
storungen nach einem
Schlagenfall—Effectivitat
eines verhaltensmedizinisch–
neuropsychologischen
Aufmerksamkeitstrainings”
(Schöttke, 1997)
“Cognitive rehabilitation for
attention deficits following
stroke” (Lincoln, Majid, &
Weyman, 2000)
Title
RCT—Treatment group (n 5 3)
received an experimental imagery
mnemonic program; control
group (n 5 3) received a pragmatic
memory rehabilitation program.
Efficacy study—Treatment 1
(n 5 2) received an intervention
of repetitive practice during a
reading task; Treatment 2 (n 5 2)
received an intervention targeting
impairment of attention during
visual scanning.
Patients with
right hemisphere
stroke and evidence
of neglect (n 5 4)
RCT—Treatment group
(n 5 6) received a memory training
program that combined 6 different
strategies; control group (n 5 6)
received repetitive practice of
memory tasks.
RCT crossover design—
computer-assisted reaction
training program
RCT—Treatment group (n 5 16)
received attentional training
program; control group (n 5 13)
received standard care.
Intervention
Mixed etiology sample
(n 5 21) that included
stroke patients (n 5 6)
Stroke patients
(n 5 12)
Left hemisphere
stroke patients
(n 5 27)
Stroke patients
(n 5 29)
Population
Only trained task performance improved
in the treatment group compared with the
control group, and this improvement did
not transfer to global memory function or
everyday memory.
Impairment
• Improved performance
on trained memory tasks
• No transfer to untrained
tasks
The entire group showed improvement in
delayed and immediate recall; however, in
the stroke groups, there was no difference
between groups.
No objective data were obtained to
support or refute either approach.
Impairment
In the stroke group, no
significant differences
between groups
No clear efficacy of either
approach determined
Function
No effect on everyday
memory functions
Intervention was effective in improving
attentional impairment, but improvement
did not generalize to other cognitive
functions.
Intervention was effective in improving
attentional impairment, but improvement
did not generalize to improved ADL
performance.
Conclusions
Impairment
• Improved alertness
• Improved sustained
attention
Function
No effect on ADL
Impairment
Improved sustained attention
Outcomes
Table 2. Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
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The American Journal of Occupational Therapy
e55
Occupational
therapy
Psychology
Medicine
Psychology
Neuropsychology
“A comparison of two
approaches in the treatment
of perceptual problems
after stroke” (Edmans, Webster,
& Lincoln, 2000)
“The treatment of visual
neglect using feedback
of eye movements: A
pilot study” (Fanthome,
Lincoln, Drummond,
& Walker, 1995)
“The influence of visual
neglect on stroke
rehabilitation” (Kalra,
Perez, Gupta, &
Wittink, 1997)
“Microcomputer-based
rehabilitation for unilateral
left visual neglect: A randomised
controlled trial” (Robertson, Gray,
Pentland, & Waite, 1990)
“Rehabilitation by limb activation
training reduces left-sided motor
impairment in unilateral neglect
patients: a single-blind randomised
control trial” (Robertson,
McMillan, MacLeod, Edgeworth, &
Brock, 2002)
Patients with neglect
secondary to stroke
(n 5 36)
Patients in an inpatient
rehabilitation hospital
setting with neglect
secondary to stroke
(n 5 36)
Patients with neglect
secondary to stroke
(n 512)
Patients in an
inpatient rehabilitation
hospital with neglect
secondary to stroke
(n 5 12)
Patients in an
inpatient rehabilitation
hospital with neglect
secondary to stroke
(n 5 80)
RCT—Treatment group
received limb activation
training plus perceptual
training (n 5 17); control
group (n 5 19) received
perceptual training only.
RCT—Treatment group
(n 5 20) received
computer scanning and
attention training; control
group (n 5 16) received
recreational computing.
RCT—Treatment group
(n 5 9) received
spatiomotor cueing
with an early emphasis
on function; control
group (n 5 3) received
standard care.
RCT—Treatment group
(n 5 9) received an eye
movement feedback
treatment; control group
(n 5 3) received no
treatment.
RCT—Group 1 (n 5 40)
received a transfer of
training approach;
Group 2 (n 5 40)
received the functional
approach for perceptual
treatment.
(Continued)
Limb activation training can improve
impairment in left side motor function;
impact on everyday life function was not
assessed.
The use of computer training is not
supported as a method to improve neglect.
Impairment
No significant differences
between groups in
neglect at 6 months
Impairment
Significant improvement
in left side motor function for
treatment group compared
with controls
Although the results of this study showed
that the treatment group trended toward
improved ADL performance, the results
were not significant.
Feedback from eye movements had no
significant effect on eye movements or
neglect symptoms poststroke.
Results provided no clear indication that
one treatment approach was better than the
other; however, both groups improved on
measures of perception and self-care. The
time frame of the intervention, however,
could indicate that findings were
attributable to spontaneous recovery.
Function
Significantly lower
median days in
hospital for treatment
group compared with
controls
No significant difference
in ADL function
Impairment
No significant
differences between
groups in neglect
or eye movements
over time
Function
No difference
between groups
in ADL performance.
Overall improvements
in both groups
Impairment
• No significant
differences between
groups in perceptual
impairment
• Overall improvements
in both groups
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e56
July/August 2011, Volume 65, Number 4
Psychology
Physical medicine
and rehabilitation
“Visual scanning training effect
on reading-related tasks in
acquired right brain damage”
(Weinberg et al., 1977)
“Unilateral neglect syndrome
rehabilitation by trunk rotation
and scanning training” (Wiart
et al., 1997)
Patients with neglect
secondary to stroke
(n 5 11)
Patients with neglect
secondary to stroke
(n 5 22)
Patients with neglect
secondary to stroke
(n 5 57)
RCT—Treatment group
(n 5 5) received scanning
task with hemiblinding
goggles; control group
(n 5 6) received just
scanning task.
RCT—Treatment group
(n 5 11) received Bon
Saint Come’s device
(voluntary trunk rotation);
control group (n 5 11)
received standard
care.
RCT—Treatment group
(n 5 25) received visual
scanning training; control
group (n 5 32) received
standard care.
RCT (4 groups)—Group 1
(n 5 5) received Training 1
(visuospatial and
visuoconstructive tasks);
Group 2 (n 5 5) received
Training 1 plus TENS;
Group 3 (n 5 5) received
Training 2 (cueing and
feedback); Group 4 (n 5 5)
received Training 2 plus TENS.
RCT—Treatment group
(n 5 18) received 15-diopter
Fresnel prism glasses;
control group (n 5 21)
received standard care.
Intervention
Note. ADL 5 activity of daily living; RCT 5 randomized controlled trial; TENS 5 transcutaneous electrical nerve stimulation.
Neuropsychology
Psychology
“Different cognitive trainings
in the rehabilitation of
visuo-spatial neglect” (Rusconi,
Meineke, Sbrissa, &
Bernardini, 2002)
“Viewing less to see better”
(Zeloni, Farne, & Baccini, 2002)
Patients with neglect
secondary to stroke
or hemianopsia
(n 5 39)
Physical medicine
and rehabilitation
“Fresnel prisms improve
visual perception in stroke
patients with homonymous
hemianopia or unilateral
visual neglect” (Rossi,
Kheyfets, & Reding, 1990)
Patients with neglect
secondary to stroke
(n 5 20)
Population
Profession
Title
Impairment
Significant improvement
in neglect for treatment
group compared with
controls immediately
and 1 wk posttreatment
Function
Significant improvement in
ADL for treatment group
compared with controls
Impairment
Significant improvement
in neglect for treatment
group compared with
controls
Impairment
Significantly greater
improvement in scanning
for treatment group
compared with controls
Impairment
Improvement in neglect
symptoms for all groups;
treatment effect greater
in Training 1
Function
No difference between
groups in ADL performance
Impairment
Significant improvement
in perception, neglect, and
visual field sight for treatment
group compared with controls
Outcomes
Table 2. Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke (cont.)
Hemiblinding goggles were shown to
improve neglect; however, the impact
of this treatment on function was not
assessed.
The Bon Saint Come’s device was
shown to improve impairment in
neglect and improve ADL function.
Further study was recommended.
Visual scanning training for
neglect can improve scanning
abilities; however, the impact
on function was not assessed.
The use of TENS associated with
any treatment for neglect is not
supported to improve symptoms.
The impact of intervention on
functional outcomes was
not assessed.
Fresnel prisms were shown to
improve impairment associated
with neglect or hemianopsia;
however, there was no difference
between groups in function.
Conclusions
disconcerting for clients but presents a
unique opportunity for occupational therapy to contribute to this body of knowledge.
Cognitive rehabilitation approaches are
largely impairment focused and often give
little consideration to the environmental
context in which clients with cognitive dysfunction have difficulty (Bowen & Lincoln,
2007; das Nair & Lincoln, 2007; Lincoln
et al., 2000). Although transferability and
generalization are critical to every intervention approach used in rehabilitation, it
can be argued that they are most important
in the area of cognitive rehabilitation. Occupational therapists are trained to collectively evaluate the person, the environment,
and the occupation to improve client
participation in everyday life (Christiansen,
Baum, & Bass Haugen, 2005). Intervention approaches for cognitive rehabilitation
that independently address the person, the
environment, or the occupation have been
shown not to lead to improvement in participation. All three contexts must be taken
into account, and occupational therapists
have established intervention approaches that
do just that. For example, the Cognitive
Orientation to daily Occupational Performance model (CO–OP; McEwen,
Polatajko, Huijbregts, & Ryan, 2009,
2010; Polatajko, McEwen, Ryan, & Baum,
2009) was originally designed for children
but has recently been adapted for use with
people with poststroke cognitive dysfunction. The CO–OP model uses cognitive
strategy training to help people compensate
for cognitive loss, and in preliminary studies
it has been shown to improve participation even in untrained tasks. However, researchers have not conducted the studies
necessary to demonstrate that intervention approaches such as CO–OP are effective in helping people with cognitive
dysfunction participate in their daily life
activities. Conducting effectiveness studies needs to be at the forefront of occupational therapy’s research agenda to
enable the profession to achieve the goal
of being evidence based.
Conclusion and Future Directions
This article has highlighted the pressing
need to conduct effectiveness research to
support occupational therapy’s role in re-
habilitation, disability, and participation.
The profession’s goal of being evidence
based is not only necessary to achieve the
Centennial Vision but also critical for the
future success and growth of the profession.
One of the most pressing populations
needing to be addressed is people with
poststroke cognitive dysfunction, a population identified as a priority by the AOTA Research Advisory Panel (2009). As a
whole, evidence is lacking to support occupational therapy practice with this population. The state of the evidence in this
area, reviewed in this article, indicates that
future research should take into account
the following recommendations:
1. Intervention approaches addressing
cognitive dysfunction poststroke should
include participation in everyday life activities as an outcome measure. Past research and available evidence have
shown that interventions in common
use have a limited impact on changing
everyday life outcomes for this client
population.
2. Future intervention development
should include methodologies to improve performance in everyday life for
people with cognitive dysfunction poststroke. Generalization and transfer of
cognitive intervention approaches are
problematic and need to be addressed
at the onset of intervention development. Intervention approaches that do
not take into account the context in
which an activity will be performed will
not produce changes in everyday life
participation.
3. The development and testing of cognitive intervention approaches should
be carried out by a multidisciplinary
team. Cognition is an overarching factor in all areas of function, and different professions have different expertise
in addressing cognitive dysfunction.
Physical therapists understand how
cognition affects motor performance,
speech therapists understand how
cognition affects language, neuropsychologists understand how to capture
cognitive dysfunction through standardized assessments, and occupational therapists understand how
cognition supports performance in
everyday life. Collaboration on mul-
tidisciplinary teams will enable occupational therapists to best contribute to
the development of the science to support their role in this practice area. s
Acknowledgments
I thank the Cognitive Rehabilitation Research Group in the Program in Occupational Therapy at Washington University
and, in particular, Colleen Fowler for their
support with this article.
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