CENTENNIAL VISION

Rehabilitation, Disability, and Participation Research:

Are Occupational Therapy Researchers Addressing
Cognitive Rehabilitation After Stroke?

ONLINE ONLY

Timothy J. Wolf

KEY WORDS I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to
 activities of daily living 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 rehabil-
 cognition disorders
itation after stroke. The review revealed one intervention effectiveness study that addressed cognitive re-
 rehabilitation habilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence
 review in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive
 stroke dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive
 treatment outcome 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
A key component of the American
Occupational Therapy Association’s
(AOTA’s) Centennial Vision is the desire
of Medicine, St. Louis, MO 63108; wolft@wustl.edu
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 estab-
lish a list of comparative effectiveness re-
search 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 commu-
nity 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 com-
munity, success in achieving the goal to be
evidence based will also require each occu-
pational therapy practitioner to contribute
his or her part. The production of evidence
to support occupational therapy services is
only truly effective when practitioners in-
tegrate 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 pro-
duced in all areas of occupational therapy
practice and the dissemination of this evi-
dence in an effective manner to practitioners.
As part of the development process
related to the Centennial Vision, occupa-
tional 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, dis-
ability, 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 speci-
fied in the other practice areas improve their
participation in everyday life activities. This
practice area includes people with Alz-
heimer’s disease, traumatic brain injury (TBI),
chronic pain, multiple sclerosis, spinal cord
injury, Parkinson’s disease, and stroke; it also
encompasses driving and community mo-
bility 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 ade-
quately addressed and which require more
attention. Therefore, the purpose of the re-
view described in this article was twofold: (1)
to summarize and evaluate the rehabilitation,
disability, and participation research pub-
lished 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 partic-
ipation: 20 studies (34.5%) were ef-
fectiveness 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 phe-
nomenon; 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,
The American Journal of Occupational Therapy
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disability, and participation literature
published in AJOT in 2009 and 2010 is
a positive sign that occupational therapy
researchers are addressing the goal of be-
ing evidence based, given that effective-
ness 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, non-
randomized 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 con-
sidered 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 treat-
ment approaches targeting both impairment-
level 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 improve-
ment 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 dys-
function 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 par-
ticipation (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 ef-
fectiveness studies (n 5 5) involved hand
injury (Hall, Lee, Page, Rosenwax, & Lee,
2010; Stapanian, Stapanian, & Staley,
2010), arthritis ( Jack & Estes, 2010), lym-
phedema (McClure, McClure, Day, &
Brufsky, 2010), and acute care rehabil-
itation (Thorne, Sauve, Yacoub, & Guitard,
2009). Although collectively, the studies
related to rehabilitation, disability, and
participation published in AJOT during this
period demonstrate that occupational ther-
apy 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 reha-
bilitation, 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 de-
velopment and testing studies, or studies
that explored the link between occupa-
tional engagement and health. All four of
these areas serve a key role in the contin-
uum of research and are ultimately neces-
sary for the development of evidence to
support the profession. For example, effi-
ciency 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 effec-
tiveness 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 real-
world 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
e47
 Table 1. Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010
e48
Author/Year
Carver (2009)
Earley, Herlache, &
Skelton (2010)
Fong & Howie (2009)
Giuffrida, Demery,
Reyes, Lebowitz, &
Hanlon (2009)
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Goverover,
Arango-Lasprilla,
Hilary, Chiaravalloti, &
DeLuca (2009)
Goverover, Chiaravalloti, &
DeLuca (2010)
July/August 2011, Volume 65, Number 4
Level of
Evidence Content Area Sample Methods Outcomes
V TBI Inpatient rehabilitation Case study Function
patient with TBI (n 5 1) Improved independence with ISC
Intermittent Goal was to improve independence with
self-catheterization (ISC) ISC through construction and use of splint.
Treatment with assistive
technology
V Stroke Chronic stroke patient Case study with pre–post assessment Impairment
4 years post-CVA (n 5 1) Improved ROM, MMT, pinch/grip
Upper-extremity dysfunction Patient received mCIMT with home
exercise program (4 weeks). Function
mCIMT Improved self-rating of IADL performance
II ABI Outpatient rehabilitation RCT with matched pairs (2 groups) Impairment
patients in Hong Kong Improved total score and score on one
Cognitive dysfunction Both groups received cognitive training
with moderate ABI (n 5 33) subtest of metacomponents and executive
program. function
Problem-solving treatment
Treatment group (n 5 16) received
Function
additional problem-solving training. No significant differences
II TBI Patients with chronic Case control Impairment
cognitive impairment after Improvements in all groups from baseline
Cognitive dysfunction TBI (n 5 6) All participants completed 3 tasks: performance, retained over 2 weeks
touch typing, 5- to 6-digit sequence
typing, and subway schedule task. Transfer of learning to another task
Effect of different practice
Patients were assigned to random demonstrated by random practice group
schedules on improving function
practice (n 5 3) or blocked
ordered practice (n 5 3).
II TBI Patients with TBI Case control Impairment
documented by CT or MRI In both groups, better results from spaced
Cognitive dysfunction (n 510) and healthy controls All groups completed both a learning than from massed practice
paragraph and a route-learning task.
Use of spacing effect to (n 5 15) No significant difference between TBI and
Within groups, patients were split into control group
improve learning and memory either spaced or massed learning groups.
II TBI Patients with TBI Case control Impairment
documented by CT or In both groups, better results from
All groups completed 2 meal
Cognitive dysfunction MRI (n 5 10) and self-generated learning than from directed
healthy controls preparation tasks and 2 financial learning
Use of self-generated vs. (n 5 15) management tasks. One task for No significant difference between TBI and
each condition was completed using
directed strategies control groups
provided instructions, and the other
task was completed using self-generated
instructions.
 Hall, Lee, Page, Rosenwax, I Hand injury
& Lee (2010)
Hardy et al. (2010) IV
The American Journal of Occupational Therapy
Hayner, Gibson, & I Stroke
Giles (2010)
Hermann et al. (2010) V Stroke
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Jack & Estes (2010) IV
Kim & Colantonio (2010) I TBI
e49
Extensor tendon repair (ETR)
Comparison of 3 postoperative
treatment protocols
Stroke
UE spasticity
Treatment study combining
2 existing protocols
Upper extremity dysfunction
CIMT
ADL limitations
Telerehabilitation and
task-specific training
Arthritis
Lupus related
Evaluation of a different
intervention approach
Postacute rehabilitation
intervention
Improvement in community
reintegration outcomes
Hospital-based outpatient hand
clinic patients with ETR (n 5 18) with
24 total injured fingers
Outpatient clinic
patients (n 5 2) with
chronic stroke (>6 months
post-CVA) and documented
UE spasticity
Community-dwelling people
with chronic stroke
symptoms (>6 months
post-CVA; n 5 12)
Community-dwelling patient
with chronic stroke (>3 years
post-CVA; n 5 1)
Orthopedic outpatient clinic
patient with lupus-related
arthritis (n 5 1)
10 research articles from
1990 to 2007 related to
improving community
reintegration post-TBI
RCT (3 groups) Impairment
Across all time points,
All participants were assessed improvement in all groups
3, 6, and 12 wk posttreatment. Greatest treatment effect
Patients were assigned to with early active
immobilization (n 5 4), early
motion protocol
passive motion (n 5 5), or early
active motion (n 5 9) treatment groups.
Case study with pre–post assessment Impairment
Decreased spasticity
Treatment combined UE bracing with
electrical stimulation in a functional Function
training program. Improved motor function
Improvements retained at 3 mo
posttreatment
RCT (2 groups) Function
Improved self-rating of performance and
Groups were stratified by more or less
satisfaction in both groups
impaired. Therapeutic improvement a factor of
Treatment group (n 5 6) received CIMT treatment intensity and not related to
protocol. protocol followed
Control group (n 5 6) received bilateral
treatment protocol.
Case study with pre–post assessment Impairment
Improved UE movement
Patients were treated with telerehabilitation
protocol to improve
Function
ADLs (4 weeks). Improved motor function
Improved self-rating of performance and
satisfaction
Case study with pre–post Function
assessment Improved performance on all functional
tasks addressed in treatment
Patients received treatment using the
occupational adaptation model.
Systematic review Benefits of postacute
TBI rehabilitation programs to improve
Goal was to identify evidence to community reintegration supported by 7
support postacute rehabilitation of 10 articles
intervention approaches that Occupational therapy or occupational
address community reintegration.
therapy interventions involved in all studies
Seven articles provided this evidence.
(Continued)
 e50
Table 1. Summary of Effectiveness Studies Addressing Rehabilitation, Disability, and Participation Published in the American Journal of Occupational Therapy, 2009 and 2010 (cont.)

Level of
Author/Year Evidence Content Area Sample Methods Outcomes
McClure, McClure, Day, & I Breast cancer–related Community-setting patients RCT (2 groups) Impairment
Brufsky (2010) lymphedema (BCRL) with BCRL recruited from Significantly improved bioimpedance,
local hospitals, clinics, and Treatment group (n 5 16) was flexibility, mood, and weight loss in
Evaluation of a recovery events (n 5 32) treated with breast cancer recovery treatment group compared with controls
program to improve program emphasizing exercise and
physical and emotional relaxation. Control group (n 5 16) Function
symptoms received standard care. Significantly improved quality of life in
treatment group compared with controls

Nilsen, Gillen, &
Gordon (2010)
I Stroke
UE dysfunction
Use of mental practice to
improve recovery
15 research articles published
between 1985 and 2009
focused on using mental
practice as part of a stroke
rehabilitation intervention
Systematic review
Goal was to determine whether
using mental practice is effective
in improving UE recovery poststroke.
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

Preissner (2010) V Stroke Inpatient rehabilitation Case study with pre–post assessment Function
setting stroke patient with Improved self-care performance
Cognitive dysfunction motor and cognitive Patients were treated with the task- after treatment
oriented approach.

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Use of the task-oriented dysfunction (n 5 1)
approach to improve ADL
function

Rand, Weiss, & III Stroke Community-dwelling people Pre–post assessment Impairment
Katz (2009) poststroke with executive Improvements on performance-based
Cognitive dysfunction function deficits (n 5 4) Patients were treated using VMall, assessment of executive function
a virtual supermarket, to improve
Evaluation of a multitasking multitasking.
intervention protocol

Rowe, Blanton, & IV Stroke Community-dwelling person Case study with pre–post and Impairment
Wolf (2009) with chronic stroke (5 yr longitudinal assessment Improved motor performance
UE dysfunction
post-CVA; n 5 1) Function
Patients received 2 wk of CIMT Improved self-reported function
Constraint-induced movement
treatment. Improvement retained at 5 years
therapy

July/August 2011, Volume 65, Number 4

 Stapanian, Stapanian,
& Staley (2010)
V Hand injury
Bilateral amputation of all
fingers
Evaluation of treatment
methods used
Community-dwelling person
with all fingers amputated
secondary to frostbite (n 5 1)
Case study with pre–post and Impairment
longitudinal assessment Improved ROM of thumb MP joint
posttreatment and at follow-up 17 years
Outcomes were evaluated after posttreatment
index finger residual transfer
to thumb.

Thorne, Sauve, Yacoub,
& Guitard (2009)
II Acute care Heterogeneous sample of Two-group, nonrandomized crossover Impairment
acute care patients at high No significant difference in pressure with or
Pressure sores risk to develop pressure Interface pressure was evaluated without use of the gel pad
sores (n 5 60) with and without use of gel pad
Evaluation of gel pads used to
in supine position.
decrease pressure sores

Zlotnik, Sachs, Rosenblum, V TBI Inpatient rehabilitation Case study with pre–post Function
Shpasser, & Josman (2009) Adolescents patients post-TBI (n 5 2) assessment Improved writing, mobility, and

The American Journal of Occupational Therapy

Evaluation of the independence in self-care posttreatment
Dynamic Interaction Patients were treated using the
Model (DIM) intervention DIM to improve function post-TBI.
approach

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.

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e51
 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 evi-
dence. If the occupational therapy pro-
fession is to meet the goal of being evidence
based in this practice area, the research
community must give special consider-
ation to developing lines of research in-
quiry along the research continuum,
culminating in effectiveness studies.
Poor Representation of
Several Populations
Several populations may be poorly repre-
sented in the work being produced in
rehabilitation, disability, and participa-
tion. 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, al-
though stroke and TBI affect two of the
largest populations with which occupa-
tional therapists work, thereby warranting
a special issue to highlight related work
being produced, in the past 2 years the fo-
cus on stroke and TBI created a void that
left several other major populations un-
derrepresented in AJOT. For example,
spinal cord injury (SCI) affects a large
population with which occupational ther-
apy practitioners work in a variety of re-
habilitation settings. AJOT published no
effectiveness studies in 2009 and 2010 re-
lated to the SCI population. AJOT should
give special consideration to the pro-
duction of special issues highlighting re-
search 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 re-
habilitation, disability, and participation
are case studies or have a small sample
size, which limits the generalizability of
the findings. Of the 20 effectiveness studies
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published by AJOT in 2009 and 2010 re-
lated to rehabilitation, disability, and par-
ticipation, 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). More-
over, 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 is-
sue in occupational therapy research: Suf-
ficiently powered randomized controlled
studies (Level 1 evidence) require many
resources to conduct, and few occupational
therapy scientists have the research in-
frastructure 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 rea-
sons, 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.
Outcome Measures at the
Impairment Level Cognitive Dysfunction
More than half of the rehabilitation, dis-
After Stroke
ability, and participation effectiveness
studies reported in AJOT in 2009 and
2010 (n 5 11) used impairment-level mea-
sures 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 re-
habilitation to improve participation;
however, the unique contribution of occu-
pational therapy practitioners to the health
care community is their focus on everyday
life participation. Occupational therapy re-
searchers must highlight this unique contri-
bution 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 pro-
ducing 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 cogni-
tive impairments, specifically after stroke,
as a priority population in the Occupational
Therapy Research Agenda. The review un-
dertaken for this article highlighted that al-
though evidence is being produced related
to stroke, most of this work is focused on
motor recovery and self-care. The remain-
der of this article addresses the unique needs
of people with cognitive dysfunction post-
stroke, the reasons poststroke cognitive
rehabilitation should be a priority for oc-
cupational therapy practitioners, and the
evidence being produced to support practice
in this area.
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 com-
munity’s overfocus on physical disability
and ADL performance has led to an un-
derappreciation of other deficits after
stroke that affect everyday life, particularly
cognitive impairment. Cognitive impair-
ment poststroke is prevalent: As many
July/August 2011, Volume 65, Number 4
 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 impair-
ment 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 evi-
dence). Even though this area of practice was
underrepresented in AJOT, my review of
outside repositories of stroke research dem-
onstrated that in general, insufficient evi-
dence 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 pro-
duced in an underdeveloped subcategory
of rehabilitation, disability, and partici-
pation practice: poststroke cognitive re-
habilitation. Two of the leading publicly
available repositories of evidence-based
reviews are the Cochrane Reviews (www2.
cochrane.org/reviews) and the Evidence-
Based Review of Stroke Rehabilitation
(EBRSR; www.ebrsr.com). The EBRSR is
an excellent resource for evidence to sup-
port stroke rehabilitation, but a major
limitation exists in its clinical utility related
to addressing cognitive dysfunction post-
stroke: 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-
The American Journal of Occupational Therapy
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amine available evidence to support cog-
nitive 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 deci-
sions (Mavergames et al., 2010) by sys-
tematically reviewing and assessing all
available evidence for specific inter-
ventions and populations. Cochrane Re-
views are continuously updated to ensure
that reviews provide the most current
information. Three Cochrane Reviews
addressed poststroke cognitive rehabil-
itation 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 Co-
chrane Stroke Group, and details of their
search criteria can be found in their refer-
ences 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 re-
views were included (AJOT Level I only).
Table 2 summarizes the studies identified
by the Cochrane Reviews to support cog-
nitive rehabilitation for attention, mem-
ory, and spatial neglect poststroke.
In the Cochrane Review that exam-
ined cognitive rehabilitation for attention
deficits after stroke, two trials were iden-
tified (Schöttke, 1997; Sturm & Willmes,
1991). The authors of the review con-
cluded 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 as-
sessments, and the review group therefore
concluded that no evidence either supports
or refutes the effectiveness of memory re-
habilitation 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 perfor-
mance on impairment-level testing, in-
sufficient evidence exists to support or
refute the effectiveness of any of the in-
tervention 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 pro-
duced by occupational therapy—or any
other health care profession—to support or
refute the effectiveness of cognitive re-
habilitation approaches poststroke. More-
over, none of the studies in the three
reviews demonstrated that any of the in-
tervention approaches translated to im-
provement 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 cog-
nitive 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 ap-
proaches that can improve everyday life
performance after a stroke. This situation is
e53
 Table 2. Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke
e54
Title
“Cognitive rehabilitation for
attention deficits following
stroke” (Lincoln, Majid, &
Weyman, 2000)
“Rehabilitation von
Aufmerksamkeits
storungen nach einem
Schlagenfall—Effectivitat
eines verhaltensmedizinisch–
neuropsychologischen
Aufmerksamkeitstrainings”
(Schöttke, 1997)
“Efficacy of a reaction
training on various
attentional and cognitive
functions in stroke
patients” (Sturm & Willmes,
1991)
“Cognitive rehabilitation for
memory deficits following stroke”
(das Nair & Lincoln, 2007)
“Cognitive training for memory
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deficits in stroke patients”
(Doornhein & deHaan, 1998)
“Imagery mnemonics for the
rehabilitation of memory: A
randomised group controlled trial”
(Kaschel et al., 2002)
“Cognitive rehabilitation for
spatial neglect following
stroke” (Bowen & Lincoln,
2007)
“Two approaches to treating
unilateral neglect after right
hemisphere stroke: A preliminary
investigation” (Cherney, Halper, &
Papachronis, 2003)
July/August 2011, Volume 65, Number 4
Profession Population Intervention
Neuropsychology Stroke patients RCT—Treatment group (n 5 16)
(n 5 29) received attentional training
program; control group (n 5 13)
received standard care.
Neuropsychology Left hemisphere RCT crossover design—
stroke patients computer-assisted reaction
(n 5 27) training program
Neuropsychology Stroke patients RCT—Treatment group
(n 5 12) (n 5 6) received a memory training
program that combined 6 different
strategies; control group (n 5 6)
received repetitive practice of
memory tasks.
Neuropsychology Mixed etiology sample RCT—Treatment group (n 5 3)
(n 5 21) that included received an experimental imagery
stroke patients (n 5 6) mnemonic program; control
group (n 5 3) received a pragmatic
memory rehabilitation program.
Speech language Patients with Efficacy study—Treatment 1
pathology, physical right hemisphere (n 5 2) received an intervention
medicine and stroke and evidence of repetitive practice during a
rehabilitation of neglect (n 5 4) reading task; Treatment 2 (n 5 2)
received an intervention targeting
impairment of attention during
visual scanning.
Outcomes
Impairment
Improved sustained attention
Function
No effect on ADL
Impairment
• Improved alertness
• Improved sustained
attention
Impairment
• Improved performance
on trained memory tasks
• No transfer to untrained
tasks
Function
 No effect on everyday
memory functions
Impairment
In the stroke group, no
significant differences
between groups
No clear efficacy of either
approach determined
Conclusions
Intervention was effective in improving
attentional impairment, but improvement
did not generalize to improved ADL
performance.
Intervention was effective in improving
attentional impairment, but improvement
did not generalize to other cognitive
functions.
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.
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.
 “A comparison of two
approaches in the treatment
of perceptual problems
after stroke” (Edmans, Webster,
& Lincoln, 2000)
“The treatment of visual
neglect using feedback
The American Journal of Occupational Therapy
of eye movements: A
pilot study” (Fanthome,
Lincoln, Drummond,
& Walker, 1995)
“The influence of visual
neglect on stroke
rehabilitation” (Kalra,
Perez, Gupta, &
Wittink, 1997)
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“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)
e55
Occupational Patients in an RCT—Group 1 (n 5 40)
therapy inpatient rehabilitation received a transfer of
hospital with neglect training approach;
secondary to stroke Group 2 (n 5 40)
(n 5 80) received the functional
approach for perceptual
treatment.
Psychology Patients in an RCT—Treatment group
inpatient rehabilitation (n 5 9) received an eye
hospital with neglect movement feedback
secondary to stroke treatment; control group
(n 5 12) (n 5 3) received no
treatment.
Medicine Patients with neglect RCT—Treatment group
secondary to stroke (n 5 9) received
(n 512) spatiomotor cueing
with an early emphasis
on function; control
group (n 5 3) received
standard care.
Psychology Patients in an inpatient RCT—Treatment group
rehabilitation hospital (n 5 20) received
setting with neglect computer scanning and
secondary to stroke attention training; control
(n 5 36) group (n 5 16) received
recreational computing.
Neuropsychology Patients with neglect RCT—Treatment group
secondary to stroke received limb activation
(n 5 36) training plus perceptual
training (n 5 17); control
group (n 5 19) received
perceptual training only.
Impairment Results provided no clear indication that
• No significant one treatment approach was better than the
differences between other; however, both groups improved on
groups in perceptual measures of perception and self-care. The
impairment time frame of the intervention, however,
• Overall improvements could indicate that findings were
in both groups attributable to spontaneous recovery.
Function
 No difference
between groups
in ADL performance.
 Overall improvements
in both groups
Impairment Feedback from eye movements had no
 No significant significant effect on eye movements or
differences between neglect symptoms poststroke.
groups in neglect
or eye movements
over time
Function Although the results of this study showed
 Significantly lower that the treatment group trended toward
median days in improved ADL performance, the results
hospital for treatment were not significant.
group compared with
controls
 No significant difference
in ADL function
Impairment The use of computer training is not
No significant differences supported as a method to improve neglect.
between groups in
neglect at 6 months
Impairment Limb activation training can improve
Significant improvement impairment in left side motor function;
in left side motor function for impact on everyday life function was not
treatment group compared assessed.
with controls
(Continued)
 e56
Table 2. Studies Identified by the Cochrane Reviews to Support Cognitive Rehabilitation for Attention, Memory, and Spatial Neglect Poststroke (cont.)
Title
“Fresnel prisms improve
visual perception in stroke
patients with homonymous
hemianopia or unilateral
visual neglect” (Rossi,
Kheyfets, & Reding, 1990)
“Different cognitive trainings
in the rehabilitation of
visuo-spatial neglect” (Rusconi,
Meineke, Sbrissa, &
Bernardini, 2002)
“Visual scanning training effect
on reading-related tasks in
acquired right brain damage”
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(Weinberg et al., 1977)
“Unilateral neglect syndrome
rehabilitation by trunk rotation
and scanning training” (Wiart
et al., 1997)
“Viewing less to see better”
(Zeloni, Farne, & Baccini, 2002)
July/August 2011, Volume 65, Number 4
Note. ADL 5 activity of daily living; RCT 5 randomized controlled trial; TENS 5 transcutaneous electrical nerve stimulation.
Profession Population
Physical medicine Patients with neglect
and rehabilitation secondary to stroke
or hemianopsia
(n 5 39)
Psychology Patients with neglect
secondary to stroke
(n 5 20)
Psychology Patients with neglect
secondary to stroke
(n 5 57)
Physical medicine Patients with neglect
and rehabilitation secondary to stroke
(n 5 22)
Neuropsychology Patients with neglect
secondary to stroke
(n 5 11)
Intervention
RCT—Treatment group
(n 5 18) received 15-diopter
Fresnel prism glasses;
control group (n 5 21)
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 25) received visual
scanning training; control
group (n 5 32) received
standard care.
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 5) received scanning
task with hemiblinding
goggles; control group
(n 5 6) received just
scanning task.
Outcomes
Impairment
Significant improvement
in perception, neglect, and
visual field sight for treatment
group compared with controls
Function
No difference between
groups in ADL performance
Impairment
Improvement in neglect
symptoms for all groups;
treatment effect greater
in Training 1
Impairment
Significantly greater
improvement in scanning
for treatment group
compared with controls
Impairment
Significant improvement
in neglect for treatment
group compared with
controls
Function
Significant improvement in
ADL for treatment group
compared with controls
Impairment
Significant improvement
in neglect for treatment
group compared with
controls immediately
and 1 wk posttreatment
Conclusions
Fresnel prisms were shown to
improve impairment associated
with neglect or hemianopsia;
however, there was no difference
between groups in function.
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.
Visual scanning training for
neglect can improve scanning
abilities; however, the impact
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.
Hemiblinding goggles were shown to
improve neglect; however, the impact
of this treatment on function was not
assessed.
 disconcerting for clients but presents a
unique opportunity for occupational ther-
apy 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 dys-
function have difficulty (Bowen & Lincoln,
2007; das Nair & Lincoln, 2007; Lincoln
et al., 2000). Although transferability and
generalization are critical to every inter-
vention approach used in rehabilitation, it
can be argued that they are most important
in the area of cognitive rehabilitation. Oc-
cupational therapists are trained to collec-
tively evaluate the person, the environment,
and the occupation to improve client
participation in everyday life (Christiansen,
Baum, & Bass Haugen, 2005). Interven-
tion approaches for cognitive rehabilitation
that independently address the person, the
environment, or the occupation have been
shown not to lead to improvement in par-
ticipation. 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 Per-
formance 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 dysfunc-
tion. 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 participa-
tion even in untrained tasks. However, re-
searchers have not conducted the studies
necessary to demonstrate that interven-
tion approaches such as CO–OP are ef-
fective in helping people with cognitive
dysfunction participate in their daily life
activities. Conducting effectiveness stud-
ies needs to be at the forefront of occu-
pational 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-
The American Journal of Occupational Therapy
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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 pop-
ulation identified as a priority by the AO-
TA Research Advisory Panel (2009). As a
whole, evidence is lacking to support oc-
cupational therapy practice with this pop-
ulation. 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 ac-
tivities as an outcome measure. Past re-
search 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 im-
prove performance in everyday life for
people with cognitive dysfunction post-
stroke. Generalization and transfer of
cognitive intervention approaches are
problematic and need to be addressed
at the onset of intervention develop-
ment. 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 cogni-
tive intervention approaches should
be carried out by a multidisciplinary
team. Cognition is an overarching fac-
tor in all areas of function, and differ-
ent professions have different expertise
in addressing cognitive dysfunction.
Physical therapists understand how
cognition affects motor performance,
speech therapists understand how
cognition affects language, neuropsy-
chologists understand how to capture
cognitive dysfunction through stan-
dardized assessments, and occupa-
tional therapists understand how
cognition supports performance in
everyday life. Collaboration on mul-
tidisciplinary teams will enable occu-
pational therapists to best contribute to
the development of the science to sup-
port their role in this practice area. s
Acknowledgments
I thank the Cognitive Rehabilitation Re-
search Group in the Program in Occupa-
tional Therapy at Washington University
and, in particular, Colleen Fowler for their
support with this article.
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