Task-Oriented Training With Cognitive Strategies for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012–2019)

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in activities of daily living (ADL) for adult stroke survivors?”

Current Theme(s) Reported

The main theme of the studies included in this systematic review brief is cognitive strategies with task-oriented training (i.e., mental imagery, mirror therapy, and action observation).

Clinical Scenario

Stroke is the leading cause of adult disability in the United States, with more than 7 million survivors (Tsao et al., 2022). Limitations in activities of daily living (ADL) remain high for stroke survivors in the long term (Gadidi et al., 2011), which is correlated with overall life dissatisfaction (Hartman-Maeir et al., 2007). Cognitive strategies as an adjunct with task- oriented training (TOT) have been identified to support improvement of ADL (Nilsen et al., 2014). The systematic review theme presented here addresses mirror therapy (MT), action observation (AO), and mental imagery for adults who had a stroke and the effectiveness of these cognitive strategies combined with TOT for improved ADL performance including basic ADL (BADL; i.e., Functional Independence Measure [FIM; Hsueh et al., 2002] and Barthel Index [BI; Hsueh et al., 2001]) and functional mobility (i.e., Timed Up and Go [TUG; Flansbjer et al., 2005] and Berg Balance Scale [BBS; Berg et al., 1995]).

Summary of Key Findings

Five Level 1A (meta-analyses) and one Level 1B (randomized control trial [RCT]) studies met the criteria for inclusion and provided evidence for the effectiveness of cognitive strategies as an adjunct to task-oriented training. The risk of bias for a majority of the studies was low, with one study with high risk of bias. The studies in this theme involved three main types of interventions: AO, MT, and mental imagery (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of- evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Bottom Line for Occupational Therapy Practice

The results of the included studies indicate that occupational therapy practitioners should include cognitive strategies, such as AO and MT with TOT to improve basic BADL and functional mobility for adults with stroke; however, mental imagery only for functional mobility. It should be noted that although BADL showed nonsignificant results for mental imagery, the studies were highly heterogenous; thus, more research is indicated. Regarding MT, it should be noted that both systemic reviews included two studies with e-stimulation plus MT (Louie et al., 2019; Yang et al., 2018) examining functional mobility and BADL, respectively. Thus, combing e-stimulation with MT may be beneficial for functional mobility or BADL; there needs to be more research.

Stroke recovery requires significant repetition of movement for improvement in motor function and ADL performance (Kwakkel et al., 2015; Nilsen et al., 2014); however, adults in stroke rehabilitation have limited amount of movement practice to achieve better performance (Lang et al., 2009). These cognitive adjunctive treatments not only are inexpensive, safe, and require minimal labor but also can be used to increase movement practice (Michielsen et al., 2011) and facilitate neuroplastic changes in the brain (Shih et al., 2017). Furthermore, these strategies can be implemented at all stages of stroke recovery, as there are no movement requirements (Thieme et al., 2012). In other words, these strategies can increase repetitions of movement, especially for those who have limited movement and are easily fatigued. Occupational therapy practitioners are well-suited to deliver these adjunctive cognitive trainings due to their education in physical disabilities, but more specifically stroke rehabilitation and motor control and learning. If feasible, practitioners should consider delivering these interventions for 5–6 days a week for 4–6 wk in addition to conventional therapy. In addition, regardless of the significance of the findings, the risk of any of these interventions was consistently low.