Even with moderate effect, WHERE THE HELL IS THE PROTOCOL? Survivors need to know where it is so they can tell their stroke medical 'professionals' what they need to do to get them recovered. Top down has been proven not to work, most stroke medical 'professionals' seem to be completely out-of-date on stroke research!
The effects of visual skills training on cognitive and executive functions in stroke patients: a systematic review with meta-analysis
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 41 (2024)
Abstract
The visual system and associated skills are of particular importance in stroke rehabilitation. The process of neuroplasticity involved in restoring cognitive function during this period is mainly based on anatomical and physiological mechanisms. However, there is little evidence-based knowledge about the effects of visual skills training that could be used to improve therapeutic outcomes in cognitive rehabilitation. A computerized systematic literature search was conducted in the PubMed, Medline, and Web of Science databases from 1 January 1960 to 11 Febuary 2024. 1,787 articles were identified, of which 24 articles were used for the calculation of weighted standardized mean differences (SMD) after screening and eligibility verification. The findings revealed moderate effects for global cognitive function (SMD = 0.62) and activities of daily living (SMD = 0.55) as well as small effects for executive function (SMD = 0.20) – all in favor of the intervention group. The analyses indicate that the results may not be entirely robust, and should therefore be treated with caution when applied in practice. Visual skills training shows positive effects in improving cognitive and executive functions, especially in combination with high cognitive load and in an early phase of rehabilitation. An improvement in activities of daily living can also be observed with this type of intervention. The high heterogeneity of the studies and different treatment conditions require the identification of a relationship between certain visual skills and executive functions in future research.
Introduction
Stroke is one of the most prevalent neurological diseases in the world, with incidence and mortality rates decreasing by 11.3% and 34%, respectively, since 1990 [1]. A significant general risk factor is the association with low- and middle-income countries, where 87% of the disability-adjusted life years are observed, impacting individuals at a relatively young age [2]. Individual risk factors include hypertension, air pollution, diabetes, and a diet high in fat and cholesterol [3]. Primary and secondary prevention strategies have been extensively studied in the literature and illustrate a homogeneous association between risk factors and intervention or patient behavior [4, 5]. In clinical practice, treatment starts in the acute phase up to 3 weeks after stroke, where hemodynamic and metabolic factors are crucial [6]. Treatment approaches in this phase are clearly emphasized in the literature in the area of endovascular [7, 8], exosome [9, 10], and stem cell-based [11,12,13], as well as pharmacological [14,15,16] approaches. In the subacute and early chronic phase, respectively 3–11 and up to 24 weeks after stroke, cognitive rehabilitation supports the patient in regaining normal function or compensating for deficits caused by the affected brain areas [17].
McDonald et al. [18] state that there is no consensus on an approach in current stroke rehabilitation due to a lack of evidence. They emphasize the necessity for thorough investigations into the effectiveness and applicability of the many promising innovations emerging in this field. Stinear et al. [19] similarly note the persistent reliance on conventional interventions in stroke rehabilitation, highlighting, that though these are effective in increasing quality of life and activity capacity, updated strategies are needed. They see potential for novel therapies that better address the challenges of a faster-paced, multi-media world and its multiple stressors and to achieve more rapid progress, particularly in improving executive functions and motor skills. These interventions include brain-computer interfaces [20, 21], robot-assisted therapy [22], virtual-reality rehabilitation [23], and various types of physical training [24, 25], all of which can now be delivered in a goal-directed manner outside of clinical rehabilitation as home-based interventions [26]. The common element of all these interventions is that they achieve effectiveness explicitly via neuroplasticity, i.e. the adaptation of the structures and function of the brain to intrinsic and extrinsic stimuli [27]. According to Sweatt [28], especially in cognitive and executive functions, structural plasticity is implied via long-lasting, recurrent stimuli that strengthen synapses between neurons. In contrast, functional plasticity involves the strengthening of neural connections due to constant shared activity between neurons, thus adjusting the functional connectivity between brain areas. Further, neurogenesis, the brain’s ability to form new neurons as an adaptation to change, has also taken on new importance in stroke rehabilitation [29]. Guggisberg et al. [30] illustrate that the reorganization of structural network systems can compensate for impaired cognitive and motor functions due to the loss of previous pathways. They advocate for tailored sensory stimulation and the processing of complex stimuli targeting the individually affected area of the brain and its core function. Visual sequelae affect 60% of all stroke survivors [31] and are the most disabling effect following cerebral infarction due to the anatomy of the central nervous system, which is largely dedicated to vision [32].
The role of the visual system in neuroplasticity-based stroke rehabilitation
As previously stated, current post-stroke rehabilitation approaches prioritize enhancing executive functions, recognized as pivotal for managing activities of daily living [33]. The visual system holds significant importance in shaping both structural and functional neuroplasticity, as well as neurogenesis [34,35,36]. Moreover, it has been specifically associated with the rehabilitation of executive functions in stroke patients [37]. According to Marinho et al. [38], there is also a mutual correlation between decision-making processes and executive functions in stroke patients, both of which affect information processing and motor action. The authors explicitly highlight the significance of sensory input quality in the decision-making process and thus for performance in executive functions. The significance of the visual system in these processes can be exemplified by everyday situations, such as crossing a green traffic light. In this scenario, many different visual stimuli affect the person, ultimately contributing to determining their behavior. Research suggests that the activity in the orbitofrontal cortex predicts successful recognition of visual objects and may receive visual input after initial sensory processing [39]. These give rise to predictions that guide specialized higher visual processing [40] and, according to the model of Borji et al. [41], fundamentally influence the decision on whether and how to respond to the traffic light. In addition to the visual stimuli, there are other cognitive stressors involved when responding to a traffic light, such as the noise level or the uncertainty about one’s walking speed. Mathews et al. [42] report that as the cognitive load increases, differences between conscious perception and the rapid, reflexive eye movements called saccades become more pronounced when individuals process situations. Since cognitive load and executive functions are negatively correlated [43,44,45], a bias in visual processing and thus influence on both the unconscious and conscious decision-making process is to be expected. This practical relevance of the visual system and its influence on cognitive and executive functions, as well as the transfer to activities of daily living after a stroke, serve as the objective for this paper.
The importance of investigating visual skills training in post-stroke rehabilitation is underscored by recent advances in our understanding of neuroplasticity and its role in recovery. A recent meta-analysis by Hao et al. [46] showed that the visual system plays a key role in the neuroplastic effects of virtual reality interventions in stroke patients, while Ferreira et al. [47] highlighted the importance of visual skills training during the rehabilitation process. However, visual skills-based interventions are mainly used in stroke patients for a general, interactive, and stimulating effect [48], or more recently also specifically as visual skills training for visual impairments after stroke [49]. It may be relevant for clinicians to consider whether their interventions to improve cognitive and executive function should be targeted at improving visual skills. To the authors’ knowledge, no systematic review or meta-analysis has examined the effects of visual skills training in stroke patients.
This systematic review and meta-analysis assesses the current state of research on the effects of visual skills interventions used in post-stroke rehabilitation to restore cognitive function or improve functional performance. It aims to provide relevant insights for clinical practice as well as new implications for future research.
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