The measurement and impairment of executive function after stroke and concepts for physiotherapy

Background: Physiotherapy intervention following stroke includes the performance of physical exercises that require both physical and cognitive resources. In addition to physical impairments after stroke, there also is a high prevalence of executive function impairment among this patient group. Traditionally, executive function has been associated with the domains of occupational therapy and neuropsychology. More recently, it has formed one of the defined domains of 'functional cognition', i.e. cognition required for daily activities which includes impairments that may be influential on the initiation and performance of exercise - an integral component of physiotherapy intervention following stroke. One aim of this review was to provide a description of commonly used measures of executive function after stroke which may be useful for physiotherapists. In addition, an examination of the prevalence of executive function impairment after stroke and its associations with physical performance and other variables was considered and will be discussed. Method: Five databases (CINAHL, PubMed, Embase, MEDLINE, and PsycINFO) were searched, using the keywords: executive function, stroke, physiotherapy, and executive function assessment. References in the articles identified were further screened for additional citations. The methodological quality of the articles included was evaluated using an adapted version of the Checklist for the Evaluation of Research Articles and the Physiotherapy Evidence Database (PEDro) scale. Major findings: Fourteen studies were included in this review. The randomized controlled trial was of moderate-to-high quality and the cross-sectional and longitudinal studies demonstrated substantial methodological shortcomings. The most commonly used tests of executive function were: Trail Making Test (n56), Stroop Task (n56), Digit Span Test (n54), Wisconsin Card Sorting Test (n54), and Verbal Fluency Test (n54). Six studies reported percentage of executive function impairment among people with stroke ranging from 3% to 63% and seven studies reported significant differences between mean stroke data and control or normative data in both acute and chronic stages post-stroke. Executive function impairment was associated with many aspects integral to physiotherapy rehabilitation, e.g. balance, mobility, rehabilitation participation, and activity of daily living ability. Executive function impairment was found irrespective of lesion location and severity. Conclusions: People presenting with executive function impairment may have difficulty initiating and completing a physiotherapy exercise programme and subsequently the success of rehabilitation may be compromised. Further attention of physiotherapists to the presence of executive function impairment after stroke may improve rehabilitation outcomes. However, poor methodological quality of the studies limited the strength of the conclusions of this review.