Rehabilitation of Poststroke Cognition
Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.
Rehabilitation is considered a standard for poststroke health care in the United States. At its best, clinical rehabilitation is a deductive, scientific process, guided by the known brain basis for clinical syndromes. Targeted assessment of modular and domain-specific information processing systems (our working definition of cognition) allows clinicians to form hypotheses about the nature of dysfunction and plan targeted treatments. However, current stroke rehabilitation often emphasizes compensatory strategies. In such circumstances, cognition is inadequately assessed, and as a result, disorders are tragically not diagnosed. Similarly, treatments for cognitive disorders are underprescribed and underutilized. When treatments are implemented, they may be guided by models that have not kept pace with developments in behavioral science and neuroscience. Knowledge gaps between basic research and stroke rehabilitation can limit the efficacy of tools and opportunities available for cognitive rehabilitation.
On the brighter side, these limitations present an opportunity for improving stroke rehabilitation techniques. Using a case example in a postacute rehabilitation setting, we encourage the reader to consider the evidence base for clinical applications. We briefly review four cognitive domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. We then illustrate the impact of stroke on these domains and the brain basis of common symptoms, emphasizing key concepts regarding information input, how it is represented internally, and how it is used for action preparation. Finally, we attempt to draw neuroscience and practice closer together, and suggest possible new avenues for treating these disorders.
Abstract and Introduction
Abstract
Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.
Introduction
Rehabilitation is considered a standard for poststroke health care in the United States. At its best, clinical rehabilitation is a deductive, scientific process, guided by the known brain basis for clinical syndromes. Targeted assessment of modular and domain-specific information processing systems (our working definition of cognition) allows clinicians to form hypotheses about the nature of dysfunction and plan targeted treatments. However, current stroke rehabilitation often emphasizes compensatory strategies. In such circumstances, cognition is inadequately assessed, and as a result, disorders are tragically not diagnosed. Similarly, treatments for cognitive disorders are underprescribed and underutilized. When treatments are implemented, they may be guided by models that have not kept pace with developments in behavioral science and neuroscience. Knowledge gaps between basic research and stroke rehabilitation can limit the efficacy of tools and opportunities available for cognitive rehabilitation.
On the brighter side, these limitations present an opportunity for improving stroke rehabilitation techniques. Using a case example in a postacute rehabilitation setting, we encourage the reader to consider the evidence base for clinical applications. We briefly review four cognitive domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. We then illustrate the impact of stroke on these domains and the brain basis of common symptoms, emphasizing key concepts regarding information input, how it is represented internally, and how it is used for action preparation. Finally, we attempt to draw neuroscience and practice closer together, and suggest possible new avenues for treating these disorders.
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