Enhancing Societal Participation for Stroke Survivors With Cognitive Impairments: A Randomized Controlled Trial

Abstract

Background: Returning to societal participation is an important goal for stroke survivors, but evidence for effective rehabilitation remains inconclusive. This study evaluated the efficacy of participation-focused strategy training in improving poststroke participation among community-dwelling survivors with cognitive impairments.

Methods: This multicenter, randomized trial enrolled stroke survivors with executive function impairments between January 2019 and March 2023. Participants received either strategy training (n=96) or an attention-control intervention (n=99) in 12 to 15 sessions over 8 weeks. The primary outcome was the postintervention change in participation across productivity, social, and community domains from the baseline, measured by the Participation Measure-3 Domains, 4 Dimensions. Secondary outcomes included changes in activity performance, self-efficacy, and global cognition from baseline.

Results: Eligible 195 participants were included in the intention-to-treat analysis (64 women, 32.8%; median [interquartile range] age: 62 [52-68] years). After adjusting for baseline primary outcome, stroke severity, and dose of regular rehabilitation, the strategy training group showed greater improvements in productivity and social participation compared with the control group (adjusted mean difference between groups [95% CI]: 7.89 [2.61-13.16] (P=0.004) and 0.29 [0.08-0.51] (P=0.009), respectively) from baseline to postintervention. These effects remained without adjustment, but did not persist at 3-month follow-up. No significant between-group differences were observed for any other outcomes.

Conclusions: Participation-focused strategy training significantly improved productivity and social participation among enrolled stroke survivors compared with the control intervention postintervention. Further research is warranted to confirm these findings in the oldest survivors and to explore approaches for enhancing the long-term benefits of strategy training.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03792061.

Keywords: cognitive dysfunction; rehabilitation; social participation; strategy training; stroke.

Figure 1. CONSORT flow diagram.

CI indicates control intervention; CONSORT, Consolidated Standards of Reporting Trials; and OPASS, Optimizing Participation after Stroke through Strategy training.

Figure 2. The procedures of the experimental intervention.

Figure 3. Postintervention responders by groups and participation domains.

A, Percentage of participants who met or exceeded the minimal clinically important improvement in the frequency dimension of productivity, social, and community participation. B, Percentage of participants who met or exceeded the minimal clinically important improvement in the difficulty dimension of participation domains. Asterisk denotes significant difference between groups (P <0.05) using Fisher exact test. CI indicates control intervention (n=99); and OPASS, Optimizing Participation after Stroke through Strategy Training (n=96).

Figure 4. Participation outcome over time that is separated by male and female stroke survivors.

A, Scatterplots of individual frequency scores. (B), Scatterplots of individual difficulty scores. Participants at each time point are listed. Unadjusted mean and 95% CI were illustrated for each subgraph. OPASS indicates Optimizing Participation after Stroke through Strategy Training; and T1, baseline; T2, postintervention; T3, 3‐month follow‐up.

Figure 5. Linear correlation between baseline and change scores in social participation and productivity.

Graph presents scatterplot, trend line, and 95% CI. CI indicates control intervention (n=99); and OPASS Optimizing Participation after Stroke through Strategy Training (n=96).