Summary of findings 1. Occupational therapy compared to usual care for people with stroke with cognitive impairment.
| Occupational therapy compared to usual care for people with stroke with cognitive impairment | ||||
| Patient or population: adults with cognitive impairment after stroke Setting: inpatient and outpatient hospital, rehabilitation centre, and home settings Intervention: occupational therapy Comparison: usual care | ||||
| Outcomes | Anticipated absolute effects* (95% CI) | No of participants (studies) | Certainty of the evidence (GRADE) | Comments |
| With occupational therapy | ||||
| 1. BADL (primary outcome) | ||||
| 1a. BADL (postintervention) Assessed with: FIM Scale: 18–126 (higher is better) Follow‐up: 2–12 weeks |
MD 2.26 higher (0.17 higher to 4.22 higher) | 336 (6 RCTs) | ⊕⊕⊝⊝ Lowa,b | Occupational therapy may result in little to no meaningful clinical difference in BADL (postintervention). BADL improved by 2.19 points on the FIM scale, which ranges from 18 (total assist) to 126 (complete independence). This difference is well below the MCID for the FIM, which has been established as 22 points for people with stroke (Beninato 2006). |
| 1b. BADL (3‐month follow‐up) Assessed with: FIM Scale: 18–126 (higher is better) Follow‐up: 3 months |
MD 10.00 higher (0.54 lower to 20.55 higher) | 73 (2 RCTs) |
⊕⊕⊝⊝ Lowb,c | There was insufficient evidence of an effect of occupational therapy on BADL at 3‐month follow‐up. |
| 1c. BADL (6‐month follow‐up) Assessed with: FIM Scale: 18–126 (higher is better) Follow‐up: 6 months |
MD 11.38 higher (1.62 higher to 21.14 higher) | 73 (2 RCTs) | ⊕⊕⊝⊝ Lowb,c | Occupational therapy may result in little meaningful difference in BADL at 6‐month follow‐up. This MD does not reach the FIM MCID of 22 points (Beninato 2006). |
| 2. IADL and other ADL/IADL | ||||
| 2a. IADL (postintervention) Assessed with: 'IADL scale', Lawton & Brody Instrumental Activities of Daily Living scale (higher is better) Follow‐up: 8–12 weeks |
SMD 0.94higher (0.41 higher to 1.47 higher) | 88 (2 RCTs) | ⊕⊝⊝⊝ Very lowb,d,e | The evidence is very uncertain about the effect of occupational therapy on IADL (postintervention). |
| 2b. Other ADL/IADL (postintervention) Assessed with: 'IADL scale' (higher is better) Follow‐up: 10 days to 2 weeks |
MD 2.61 higher (0.1 higher to 5.12 higher) | 111 (3 RCTs) | ⊕⊝⊝⊝ Very lowb,f | The evidence is very uncertain about the effect of occupational therapy on other IADL (postintervention). |
| 3. Community integration and participation | ||||
| 3a. Self‐reported community integration or participation (postintervention) Assessed with: CIQ, USER‐P (Restriction subscale) (higher is better) Follow‐up: 12–18 weeks |
SMD 0.09 higher (0.35 lower to 0.54 higher) |
78 (2 RCTs) |
⊕⊕⊝⊝ Lowb,g | There was insufficient evidence of an effect on community integration and participation (postintervention). |
| 4. Global cognitive function | ||||
| 4a. Global cognitive functional performance (sensitivity analysis) (postintervention) Assessed with: MoCA, MMSE, BNIS (higher is better) Follow‐up: 10 days to 18 weeks |
SMD 0.35 higher (0.16 higher to 0.54 higher) | 432 (9 RCTs) | ⊕⊕⊝⊝ Lowh | Occupational therapy may slightly increase global cognitive functional performance (postintervention). The difference between groups equates to 1.63 points on the MoCA (95% CI 0.75 to 2.52). Therefore, on average, participants receiving the intervention had improved global cognitive functional performance by 1.63 points on the MoCA scale. This difference exceeds the anchor‐based MCID of the MoCA for stroke rehabilitation patients of 1.22 but not the distribution‐based MCID of 2.15 (Wu 2019). |
| 5. Attention | ||||
| 5a. Visual attention overall (postintervention) Assessed with: VCPT, Schulte's Tables, TMT‐A, Attentive Matrices, Stroop Colour Word, CWIT‐3 (lower is better) Follow‐up: 10 days to 12 weeks |
SMD 0.31 lower (0.47 lower to 0.15 lower) | 620 (13 RCTs) | ⊕⊕⊝⊝ Lowi | Occupational therapy may result in little to no difference in visual attention overall (postintervention). The difference between groups equates to 17.31 seconds (95% CI 8.38 to 26.24). |
| 5b. Visual attention overall (3–6 months' follow‐up) Assessed with: TMT‐A, VCPT, CWIT‐3, Stroop Colour Word (lower is better) Follow‐up: 3–6 months |
SMD 0.32 lower (0.55 lower to 0.09 lower) | 293 (5 RCTs) | ⊕⊕⊝⊝ Lowb,j | Occupational therapy may result in little to no difference in visual attention overall (at 3–6 months' follow‐up). The difference between groups equates to 17.87 seconds (95% CI 5.03 to 30.71). |
| 5c. Sustained visual attention (postintervention) Assessed with: VCPT, Schulte's Tables, TMT‐A (lower is better) Follow‐up: 10 days to 12 weeks |
SMD 0.28 lower (0.47 lower to 0.10 lower) | 463 (10 RCTs) | ⨁⨁⨁⊝ Moderatek | Occupational therapy likely improves sustained visual attention slightly (postintervention). The difference between groups equates to 15.63 seconds (95% CI 5.58 to 26.24). |
| 6. Memory | ||||
| 6a. Working memory (postintervention) Assessed with: Span board reversed, TMT‐B, Visual Span Backwards test, PASAT 2.4 (higher is better) Follow‐up: 4–12 weeks |
SMD 0.45 higher (0.26 higher to 0.65 higher) | 420 (8 RCTs) | ⊕⊕⊝⊝ Lowl | Occupational therapy may increase working memory slightly (postintervention). The difference between groups equates to 59.9 seconds (95% CI 34.60 to 86.5). |
| 6b. Immediate verbal memory span (postintervention) Assessed with: Digit Span Forwards, Listening Span, Verbal paired associates (higher is better) Follow‐up: 4–18 weeks |
SMD 0.35 higher (0.14 higher to 0.56 higher) | 357 (8 RCTs) | ⊕⊝⊝⊝ Very lowb,m | The evidence is very uncertain about the effect of occupational therapy on immediate verbal memory span (postintervention). The difference between groups equates to a difference of 0.76 (95% CI 0.31 to 1.22), equating to a difference of recall of 1 digit on the Digit Span forwards test. |
| 6c. Immediate spatial memory span (postintervention) Assessed with: Block Span Forward, Visual Span test, Span Board Forwards, Spatial Span, Corsi's test (higher is better) Follow‐up: 4–18 weeks |
SMD 0.27 higher (0.03 higher to 0.50 higher) | 292 (7 RCTs) | ⊕⊕⊝⊝ Lowb,n | Occupational therapy may result in little to no difference in immediate spatial memory span. |
| 7. Executive function | ||||
| 7a. Executive functional performance overall (postintervention) Assessed with: FAB, BADS, CWIT‐4, PM47, Mental rotation test (higher is better) Follow‐up: 10 days to 3 months |
SMD 0.49 higher (0.31 higher to 0.66 higher) | 550 (11 RCTs) | ⊕⊝⊝⊝ Very lowe,o | The evidence is very uncertain about the effect of occupational therapy on executive functional performance overall. The difference equates to 1.41 (95% CI 0.89 to 1.89) on the FAB. Therefore, on average, participants receiving the intervention improved executive functional performance by 1.41 points on the FAB scale, which ranges from 0 to 18. |
| 7b. Cognitive flexibility (postintervention) Assessed with: CWIT‐4 (lower is better) Follow‐up: 4 weeks and 3 months |
SMD 1.50 lower (2.20 lower to 0.80 lower) | 43 (2 RCTs) | ⨁⨁⊝⊝ Lowp,q |
Occupational therapy may slightly increase ability to think flexibly (postintervention). The difference equates to 4.5, which may be considered a clinically meaningful change on the CWIT‐4. |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ADL: activities of daily living; BADL: basic activities of daily living; BADS: Behavioural Assessment of Dysexecutive Syndrome; BNIS: Barrow Neurological Institute Screen for Higher Cerebral Functions; CI: confidence interval; CIQ: Community Integration Questionnaire; CWIT‐3: Color Word Interference Test – Inhibition subscale (Condition 3); CWIT‐4: Color Word Interference Test Cognitive flexibility (switching) subscale (Condition 4); FAB: Frontal Assessment Battery; FIM: Functional Independence Measure; IADL: instrumental activities of daily living; MCID: minimal clinically important difference; MD: mean difference; MoCA: Montreal Cognitive Assessment; MMSE: Mini‐Mental State Examination; PASAT 2.4: Paced Auditory Serial Addition Test; PM47: Raven's Colored Progressive Matrices 47; RCT: randomised controlled trial; SMD: standardised mean difference; TMT‐A: Trail making Test A; TMT‐B: Trail making Test B; USER‐P: Utrecht Scale for Evaluation of Rehabilitation‐Participation; VCPT: Visual Continuous Performance Test. | ||||
| GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||
aDowngraded one level due to risk of bias: all studies had no blinding of participants and personnel and some studies were unclear for selection bias but of most concern was Jiang 2016, which was at high risk of bias for attrition bias and it was by far the largest study and had the highest weighting in the analysis. bDowngraded one level due to imprecision: the sample size was below 400 considered a general rule for adequate sample size (Schünemann 2013). cDowngraded one level due to risk of bias: Skidmore 2015a was unclear for allocation concealment and both studies had no blinding of participants and personnel. dDowngraded one level due to risk of bias: both studies were unclear for allocation concealment. eDowngraded one level due to inconsistency: there was substantial heterogeneity that was not clearly explained. fDowngraded two levels due to very serious concerns about risk of bias: all were unclear for allocation concealment, two were unclear for sequence generation, all studies had no blinding of participants and personnel and two were unclear for attrition bias. gDowngraded one level due to risk of bias: both studies were unclear for allocation concealment, one was unclear and the other high risk for blinding of participants and personnel. hDowngraded two levels due to very serious concerns about risk of bias: all were unclear for allocation concealment except Jiang 2016; Jiang 2016, the highest weighted study, had potential for high risk for incomplete outcome data. iDowngraded two levels due to very serious concerns about risk of bias: all were unclear for allocation concealment except Barker‐Collo 2009 and Bo 2019; Bo 2019 was unclear for incomplete outcome data and was one of the highest weighted studies and eight were unclear for incomplete outcome data. jDowngraded one level due to risk of bias: three of the smaller weighted studies were unclear for allocation concealment and Bo 2019, the highest weighted study, was high risk for incomplete outcome data. kDowngraded one level due to risk of bias: all but one study was unclear for allocation concealment, with Barker‐Collo 2009 at low risk. lDowngraded two levels due to very serious concerns about risk of bias: six studies had unclear allocation concealment, two studies with high weight were low risk; Bo 2019, with the highest weighting, was high risk for incomplete outcome data and four were unclear for this criterion. mDowngraded two levels due to very serious concerns about risk of bias: Bo 2019 contributed the most and had high risk for incomplete outcome data and Zuchella 2014, the next heavily weighted was unclear for allocation concealment. Remaining studies were unclear for allocation concealment. All studies had no blinding of participants and personnel. nDowngraded one level due to risk of bias: all studies had unclear allocation concealment and three were unclear for incomplete outcome data. oDowngraded two levels due to very serious concerns about risk of bias: all but the highest weighted study (Bo 2019) were unclear for allocation concealment and Bo 2019 was high risk for incomplete outcome data and four other studies were unclear for this criterion. pDowngraded one level due to imprecision: the sample size is below 400 considered a rule of thumb for adequate sample size (Schünemann 2013). qDowngraded one level due to risk of bias: unclear for allocation concealment and high risk for blinding for both studies and unclear detection bias for Lundqvist 2010.