Effects of Digital Cognitive Rehabilitation on Functional Performance After Stroke: A Systematic Review and Meta-Analysis of ADL and IADL Outcomes

Abstract

Background/Objectives: Digital cognitive rehabilitation (DCR) is increasingly used for post-stroke cognitive rehabilitation, but its effects on functional performance remain insufficiently synthesized. This review examined the effects of DCR on activities of daily living (ADL) and instrumental activities of daily living (IADL) after stroke. Methods: This review followed the PRISMA 2020 statement and was registered in PROSPERO. Five bibliographic databases and Google Scholar were searched for randomized controlled trials published between 2010 and 2025. Methodological quality, risk of bias, and certainty of evidence were assessed using the PEDro scale, Cochrane RoB 2 tool, and GRADE framework. Effect sizes were calculated as Hedges’ g and pooled using random-effects models. Results: Eighteen RCTs were included in the systematic review. No included study directly assessed functional cognition. PEDro scores ranged from 4 to 8, and most studies were rated as having “some concerns” for overall risk of bias. DCR showed statistically significant moderate effects on ADL performance (k = 12, N = 503; Hedges’ g = 0.463, 95% CI = 0.241–0.684, p < 0.001; I2 = 36.73%) and IADL performance (k = 4, N = 186; Hedges’ g = 0.580, 95% CI = 0.248–0.912, p = 0.001; I2 = 23.49%). No statistically significant subgroup differences or meta-regression associations were detected for ADL outcomes, but these exploratory analyses were limited by the small number of studies. The certainty of evidence was moderate for ADL outcomes and low for IADL outcomes. Conclusions: DCR may improve ADL performance after stroke. IADL effects were also significant, but the evidence for IADL outcomes remains limited. Prediction intervals for both outcomes indicated uncertainty about the effects that may be observed in future trials. Because no included study directly assessed functional cognition, these findings should be interpreted as evidence on ADL and IADL functional performance outcomes, not as direct evidence of effects on functional cognition. Clinical application should consider methodological limitations, risk-of-bias concerns, and certainty of evidence. Future RCTs should include validated performance-based measures of functional cognition.