Cognitive rehabilitation interventions after stroke: protocol for a systematic review and meta-analysis of randomized controlled trials

Mobile Application Applied for Cognitive Rehabilitation: A Systematic Review

The COVID-19 pandemic has increased the demand for home rehabilitation services, leading to the development and rising demand for cognitive rehabilitation apps. However, a comprehensive analysis of the content and effectiveness of these apps is needed. This study systematically reviewed and analyzed the literature on mobile apps for cognitive rehabilitation. One researcher and an external expert conducted the study selection, data extraction, and quality assessment following the PRISMA Checklist 2020 guidelines. Our review of 18 studies identified 8 randomized controlled trials (RCTs) (44.44%) of high quality and 10 non-RCT studies (55.56%) of moderate quality. Overall, 16 of the 18 studies (88.88%) demonstrated positive clinical implications for cognitive function after using cognitive rehabilitation apps. Eight studies showed a correlation between app use and improved cognitive function, and four highlighted the potential for cognitive function evaluation through apps. All studies employed various occupational therapy (OT) intervention approaches, with prevention being the most common (100%), followed by establishment and restoration (83.33%), maintenance (77.77%), and creation and promotion (38.88%). This study clinically validates the effectiveness of cognitive rehabilitation mobile applications from an occupational therapy perspective.

Computer-aided cognitive training combined with tDCS can improve post-stroke cognitive impairment and cerebral vasomotor function: a randomized controlled trial

BACKGROUND

Post-stroke cognitive impairment (PSCI) is the focus and difficulty of poststroke rehabilitation intervention with an incidence of up to 61%, which may be related to the deterioration of cerebrovascular function. Computer-aided cognitive training (CACT) can improve cognitive function through scientific training targeting activated brain regions, becoming a popular training method in recent years. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation technique, can regulate the cerebral vascular nerve function, and has an effect on the rehabilitation of cognitive dysfunction after stroke. This study examined the effectiveness of both CACT and tDCS on cognitive and cerebrovascular function after stroke, and explored whether CACT combined with tDCS was more effective.

METHODS

A total of 72 patients with PSCI were randomly divided into the conventional cognitive training (CCT) group (n = 18), tDCS group (n = 18), CACT group (n = 18), and CACT combined with tDCS group (n = 18). Patients in each group received corresponding 20-minute treatment 15 times a week for 3 consecutive weeks. Montreal Cognitive Assessment (MoCA) and the Instrumental Activities of Daily Living Scale (IADL) were used to assess patients' cognitive function and the activities of daily living ability. Transcranial Doppler ultrasound (TCD) was used to assess cerebrovascular function, including cerebral blood flow velocity (CBFV), pulse index (PI), and breath holding index (BHI). These outcome measures were measured before and after treatment.

RESULTS

Compared with those at baseline, both the MoCA and IADL scores significantly increased after treatment (P < 0.01) in each group. There was no significantly difference in efficacy among CCT, CACT and tDCS groups. The CACT combined with tDCS group showed greater improvement in MoCA scores compared with the other three groups (P < 0.05), especially in the terms of visuospatial and executive. BHI significantly improved only in CACT combined with tDCS group after treatment (p ≤ 0.05) but not in the other groups. Besides, no significant difference in CBFV or PI was found before and after the treatments in all groups.

CONCLUSION

Both CACT and tDCS could be used as an alternative to CCT therapy to improve cognitive function and activities of daily living ability after stroke. CACT combined with tDCS may be more effective improving cognitive function and activities of daily living ability in PSCI patients, especially visuospatial and executive abilities, which may be related to improved cerebral vasomotor function reflected by the BHI.

TRIAL REGISTRATION NUMBER

The study was registered in the Chinese Registry of Clinical Trials (ChiCTR2100054063). Registration date: 12/08/2021.

Prevalence and factors influencing cognitive impairment among the older adult stroke survivors: a cross-sectional study

Background

Cognitive impairment as a complication in post-stroke patients has high prevalence throughout the world. However, few studies have focused on the older adult stroke survivors and explored their prevalence and factors of post-stroke cognitive impairment (PSCI). The study aims to evaluate the cognitive status of stroke patients in Hunan Province, China and to determine the potential risk factors associated with PSCI in order to identify the older adult population in advance and promote healthy aging.

Methods

This cross-sectional study was carried out from August to December, 2021. A total of 520 stroke survivors from 6 tertiary hospitals were randomly selected. The information was collected using the general questionnaire, the Barthel Index Rating Scale and the Mini-mental State Examination (MMSE). Analysis was based on descriptive statistics, chi-square test and the significant variables were included in multivariate logistic regression. The reporting of this cross-sectional study followed the STROBE checklist.

Results

A total of 195 older adults (40.37%) were screened for cognitive impairment based on the results of the MMSE score. Patients in the PSCI group had a higher proportion of individuals aged 70 or older (35.90% vs. 24.65%, p<0.001). The potential risk factors for post-stroke cognitive impairment in older adults were being aged between 70 and 79 years old (OR = 3.973, 95% CI, 2.346-6.729, p<0.001), being aged 80 years or older (OR = 3.590, 95% CI, 1.373-9.387, p = 0.009), having a low level of education (OR = 9.183, 95% CI, 5.341-15.789, p<0.001), having hypertension (OR = 1.756, 95% CI, 1.121-2.753, p = 0.014), and having a dominant hemisphere lesion (OR = 1.880, 95% CI, 1.193-2.962, p<0.001).

Conclusion

The prevalence of PSCI was high among Chinese older adults, particularly those aged 80 years or older. The factors identified in our study could assist in the early identification of older adults at risk, develop personalized management plans, and promote healthy aging.

The continuous performance test aids the diagnosis of post-stroke cognitive impairment in patients with right hemisphere damage

Purpose

The purpose of the study was to investigate the time course difference of relative changes in oxygenated hemoglobin (Oxy-Hb) concentration in the prefrontal cortex (PFC) between controls and patients with post-stroke cognitive impairment (PSCI) who had right hemisphere damage (RHD) using the continuous performance test (CPT) and functional near-infrared spectroscopy (fNIRS) technology. The study aimed to evaluate the feasibility of CPT in the diagnosis and evaluation of PSCI with RHD.

Methods

A total of 16 patients with RHD (RHD group) and 32 normal subjects (control group) were recruited. The Montreal Cognitive Assessment Scale was used to assess post-stroke cognitive impairment. The CPT and fNIRS were employed to investigate task-related changes in Oxy-Hb levels.

Results

The RHD group showed significantly lower accuracy and hit rates than the control group; however, the average reaction time was significantly longer in the former. Although the two groups showed no statistically significant difference in terms of left and right PFC integral values, the mean values were greater in the RHD group. The centroid value of the right PFC was significantly higher in the RHD group than in the control group. The time course of Oxy-Hb concentrations in the PFC differed between the two groups. In the RHD group, neural compensation was observed in both prefrontal lobes; however, the rate of compensation was slower on the affected side.

Conclusion

The CPT may be helpful in the clinical diagnosis of PSCI with RHD. It may therefore be used to evaluate the effectiveness of cognitive interventions.

Effects of excitatory transcranial magnetic stimulation over the different cerebral hemispheres dorsolateral prefrontal cortex for post-stroke cognitive impairment: a systematic review and meta-analysis

Background

Post-stroke cognitive impairment (PSCI) is a significant health concern. Transcranial magnetic stimulation (TMS) is considered a promising rehabilitation therapy for improving cognition, and the effects of excitatory TMS on PSCI have received much attention in recent years. However, the effects of different cerebral hemispheres on excitatory TMS treatment of cognitive impairment have not been studied. This review aimed to study the effects of excitatory TMS over the dorsolateral prefrontal cortex (DLPFC) of different cerebral hemispheres on the cognitive function of patients with PSCI.

Methods

Literature published in PubMed, Web of Science, Embase, Cochrane Library, Scopus, and Wiley from inception to September 30, 2022, were searched. Two researchers independently performed literature screening, data extraction, and quality assessment. Furthermore, we conducted a meta-analysis using RevMan software (version 5.4) and rated the strength of evidence using GRADEpro.

Results

A total of 19 studies were included in this meta-analysis. The results showed that excitatory TMS over the left hemisphere DLPFC was significantly better in improving global cognition (SMD = 2.26, 95% CI 1.67-2.86, P < 0.00001; vs. SMD = 2.53, 95% CI 1.86-3.20, P < 0.00001), memory (SMD = 1.29, 95% CI 0.72-1.87, P < 0.0001), attention (SMD = 2.32, 95% CI 1.64-3.01, P < 0.00001), executive (SMD = 0.64, 95% CI 0.21-1.07, P = 0.004), P300 latency (SMD = 2.69, 95% CI 2.13-3.25, P < 0.00001), and depression (SMD = 0.95, 95% CI 0.26-1.63, P = 0.007) than that of the control group, but the effect on improving activities of daily living (ADL) was unclear (P = 0.03 vs. P = 0.17). Subgroup analysis further showed that excitatory TMS over the right hemisphere DLPFC was effective in improving the global cognition of PSCI patients (P < 0.00001), but the stimulation effect over the ipsilateral hemisphere DLPFC was unclear (P = 0.11 vs. P = 0.003). Additionally, excitatory TMS over the ipsilateral hemisphere DLPFC showed no statistical difference in improving ADL between the two groups (P = 0.25).

Conclusions

Compared to other hemispheric sides, excitatory TMS over the left hemisphere DLPFC was a more effective stimulation area, which can significantly improved the global cognitive function, memory, attention, executive, P300 latency, and depression in patients with PSCI. There was no apparent therapeutic effect on improving activities of daily living (ADL). In the future, more randomized controlled trials with large-sample, high quality, and follow-up are necessary to explore a usable protocol further.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022369096.

The effect of transcranial magnetic stimulation on the recovery of attention and memory impairment following stroke: a systematic review and meta-analysis

BACKGROUND

Previous studies indicated inconsistent results for the treatment effect of repetitive transcranial magnetic stimulation (rTMS) on attention and memory impairment following stroke.

METHODS

Randomized controlled trials (RCTs) on TMS for the treatment of stroke were retrieved from Online databases. Data were analyzed by RevMan 5.3 software.

RESULTS

Ten RCTs performed in China were included, with a total of 591 younger post-stroke patients ranging in age from their 40s to their 60s. The meta-analysis indicated that TMS could significantly improve the recovery of cognitive impairment following a stroke, according to the Montreal Cognitive Assessment (MoCA) score (8 studies, MD = 2.69, 95% CI: 1.44 to 3.95, P < 0.0001), the Rivermead Behavioral Memory Test (RBMT) score (7 studies, MD = 1.74, 95% CI:1.13 to 2.34, P < 0.00001), and the Modified Barthel Index (MBI) for Activities of Daily Living (3 studies, MD = 8.83, 95% CI:5.34 to 12.32, P < 0.00001). Sub-group analysis of MoCA and RBMT suggested that a low-frequency (1 Hz) stimulation exhibited similar effect with a higher-frequency (10 Hz) treatment.

DISCUSSION

TMS might effectively improve the attention and memory impairment of stroke patients without increasing side effects. But this effect needs to be verified by more multi-center, high-quality, large-sample, rigorously designed RCTs.

Resting-State Beta-Band Recovery Network Related to Cognitive Improvement After Stroke

Background

Stroke is the second leading cause of death worldwide and it causes important long-term cognitive and physical deficits that hamper patients' daily activity. Neuropsychological rehabilitation (NR) has increasingly become more important to recover from cognitive disability and to improve the functionality and quality of life of these patients. Since in most stroke cases, restoration of functional connectivity (FC) precedes or accompanies cognitive and behavioral recovery, understanding the electrophysiological signatures underlying stroke recovery mechanisms is a crucial scientific and clinical goal.

Methods

For this purpose, a longitudinal study was carried out with a sample of 10 stroke patients, who underwent two neuropsychological assessments and two resting-state magnetoencephalographic (MEG) recordings, before and after undergoing a NR program. Moreover, to understand the degree of cognitive and neurophysiological impairment after stroke and the mechanisms of recovery after cognitive rehabilitation, stroke patients were compared to 10 healthy controls matched for age, sex, and educational level.

Findings

After intra and inter group comparisons, we found the following results: (1) Within the stroke group who received cognitive rehabilitation, almost all cognitive domains improved relatively or totally; (2) They exhibit a pattern of widespread increased in FC within the beta band that was related to the recovery process (there were no significant differences between patients who underwent rehabilitation and controls); (3) These FC recovery changes were related with the enhanced of cognitive performance. Furthermore, we explored the capacity of the neuropsychological scores before rehabilitation, to predict the FC changes in the brain network. Significant correlations were found in global indexes from the WAIS-III: Performance IQ (PIQ) and Perceptual Organization index (POI) (i.e., Picture Completion, Matrix Reasoning, and Block Design).