Cognitive rehabilitation for attention deficits following stroke

Many people have problems with attention after stroke. They are not able to concentrate for prolonged periods of time and are distractible, being unable to focus on a specific task in the presence of competing information. Cognitive rehabilitation involves providing therapeutic activities to reduce the severity of a cognitive impairment following damage to the brain. The benefit of cognitive rehabilitation for impairments of attention following stroke is unclear. Our aim was to review the effect of cognitive rehabilitation on attention, and in addition on functional abilities, mood and quality of life. We identified six randomised controlled trials that compared cognitive rehabilitation with a usual care control group for people with impairment of attention. The six studies involved 223 participants. We found a significant effect of cognitive rehabilitation on divided attention at the end of the intervention period, but there was no evidence that these benefits persisted. In addition, there was no evidence to support or refute the effect of cognitive rehabilitation for other types of attention impairment or for any effect on functional abilities, mood or quality of life. The methodological quality of the trials identified and the paucity of studies means that we cannot draw conclusions about the effect of cognitive rehabilitation for attention. More research is needed. People with attentional impairments should continue to receive stroke rehabilitation services but more research is needed to identify the specific effects of specific cognitive rehabilitation.

Authors' conclusions: 

The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

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Background: 

Many survivors of stroke complain about attentional impairments, such as diminished concentration and mental slowness. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.

Objectives: 

To determine whether (1) people receiving attentional treatment show better outcomes in their attentional functions than those given no treatment or treatment as usual, and (2) people receiving attentional treatment techniques have a better functional recovery, in terms of independence in activities of daily living, mood and quality of life, than those given no treatment or treatment as usual.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (October 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library October 2012), MEDLINE (1948 to October 2012), EMBASE (1947 to October 2012), CINAHL (1981 to October 2012), PsycINFO (1806 to October 2012), PsycBITE and REHABDATA (searched October 2012) and ongoing trials registers. We screened reference lists and tracked citations using Scopus.

Selection criteria: 

We included randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. The primary outcome was measures of global attentional functions, and secondary outcomes were measures of attention domains, functional abilities, mood and quality of life.

Data collection and analysis: 

Two review authors independently selected trials, extracted data and assessed trial quality.

Main results: 

We included six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation for persisting effects on global measures of attention (two studies, 99 participants; standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.23 to 0.56; P value = 0.41), standardised attention assessments (two studies, 99 participants; P value ≥ 0.08) or functional outcomes (two studies, 99 participants; P value ≥ 0.15). In contrast, a statistically significant effect was found in favour of cognitive rehabilitation when compared with control for immediate effects on measures of divided attention (four studies, 165 participants; SMD 0.67, 95% CI 0.35 to 0.98; P value < 0.0001) but no significant effects on global attention (two studies, 53 participants; P value = 0.06), other attentional domains (six studies, 223 participants; P value ≥ 0.16) or functional outcomes (three studies, 109 participants; P value ≥ 0.21).

Thus there was limited evidence that cognitive rehabilitation may improve some aspects of attention in the short term, but there was insufficient evidence to support or refute the persisting effects of cognitive rehabilitation on attention, or on functional outcomes in either the short or long term.

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