Why cognition matters: perspectives in post-stroke motor rehabilitation research.

Abstract

Post-stroke cognitive impairment (PSCI) is common (reported prevalence 20-80%) and can limit engagement with motor rehabilitation, yet it is often overlooked in research. This perspective aims to highlight a gap in post-stroke motor rehabilitation research: whilst cognition critically impacts post-stroke motor rehabilitation, the current evidence base does not represent individuals with PSCI. We draw on peer-reviewed literature, stroke rehabilitation guidelines and ethical guidance on including adults with impaired capacity to consent. Using a narrative synthesis of selected literature and rehabilitation guidelines, we critically appraise how cognition is addressed in guideline-informing trials, highlight common cognition-related exclusion practices, and draw on illustrative examples of inclusive approaches. Consent processes are considered as a modifiable barrier to inclusion. Guideline-informing trials often exclude or underreport cognitive impairment, limiting generalisability to routine stroke populations. Barriers extend beyond capacity: studies should incorporate cognitive strategies and adopt inclusive recruitment pathways. Importantly, cognitive impairment should be distinguished from decision-making capacity, with consultee involvement where needed. Motor rehabilitation risks inequity and poor real-world translation unless trials routinely include and characterise PSCI. NIHR-INCLUDE emphasises inclusion of under-served groups, supporting the need for trials and service models that adapt interventions for cognitive impairment rather than excluding affected individuals.