Rehabilitation for Cognitive Impairment after Stroke: Exploration of Possibilities for the Delivery of Cognitive Rehabilitation

Aim: The overarching aims of this thesis are to explore the potential suitability of cardiovascular rehabilitation, an expanded version of cardiac rehabilitation, for post-stroke rehabilitation, including cognitive intervention where relevant, and to identify existing barriers and facilitators to delivery of cognitive rehabilitation for all stroke patients with cognitive impairment as part of routine post-stroke care.

Methods and results: This thesis employed an explanatory sequential mixed methods design, combining quantitative and qualitative methodologies. Four interrelated studies were conducted to address the thesis aims. The first study involved a systematic review of the literature to establish whether cardiovascular/cardiac rehabilitation, with or without a cognitive rehabilitation intervention, improved post-stroke outcomes, particularly cognitive outcomes. A limited literature demonstrated that, although cardiac rehabilitation-type interventions had no significant effect on post-stroke cognitive function, improvements in anxiety, depression, and cardiovascular fitness were evident.

The qualitative component of this thesis (Studies 2 and 3) involved semi-structured interviews with stroke and cardiac rehabilitation professionals, and the data were analysed using Thematic Analysis. The first qualitative study (Study 2) explored the potential for expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. Participants recommended a hybrid model, in which shared modules are delivered to all patients and stroke-specific education and exercise are delivered to those with stroke. Cognitive impairment was described as a barrier to cardiac rehabilitation, and the inclusion of a cognitive rehabilitation intervention could address the cognitive needs of stroke and cardiac patients simultaneously. The second qualitative study (Study 3) aimed to identify barriers and facilitators to the delivery of cognitive rehabilitation in existing stroke services, for individuals with more significant impairments who may not be eligible for cardiovascular rehabilitation. Participants highlighted the importance of the multidisciplinary team approach to stroke rehabilitation, as well as barriers to delivery of cognitive rehabilitation including inadequate resourcing, the lack of defined pathways for continuing rehabilitation in the community and poor access to stroke-specific expertise. The findings suggest that improved resourcing of psychology and neuropsychology, in particular, would promote better access to comprehensive cognitive assessment and cognitive rehabilitation. The final quantitative study of this thesis (Study 4) considered the impact of stroke, cognitive impairment and post-stroke cognitive impairment on healthcare utilisation. Stroke was associated with more frequent visits to the GP, outpatient clinics and rehabilitation services. While poor cognitive function was also associated with increased GP utilisation, cognitive impairment, with or without stroke, was associated with reduced visits to outpatient services.

Conclusion: The overall findings from this thesis indicate that adapted cardiovascular rehabilitation may be a suitable model through which to deliver rehabilitation post-stroke, including cognitive rehabilitation. Further research is needed also to establish the potential effectiveness of cardiovascular rehabilitation on post-stroke cognitive impairment. Inconsistent cognitive screening practices makes it difficult to specify the numbers of patients with stroke who would require cognitive rehabilitation, thus impacting on the capacity to identify resources needed for delivery of cognitive rehabilitation. Inadequate resourcing continues to be a major barrier to the effective delivery of stroke services in Europe and limited access to stroke-specific expertise in the community further impedes the delivery of cognitive rehabilitation. The overall results of this thesis indicate an urgent need for investment in stroke rehabilitation services across all healthcare settings, to improve access to cognitive rehabilitation post-stroke. Rehabilitation for cognitive impairment is a neglected aspect of stroke rehabilitation and the absence of appropriate cognitive care post-stroke is likely to have significant implications for healthcare services worldwide.