Abstract

Purpose
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.

Materials
We draw on peer-reviewed literature, stroke rehabilitation guidelines and ethical guidance on including adults with impaired capacity to consent.

Methods
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.

Results
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.

Conclusions
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.

IMPLICATIONS FOR REHABILITATION
Cognition should be considered in motor rehabilitation because it supports motor relearning and influences engagement and response.

Research should include stroke survivors with cognitive impairment using inclusive consent that distinguishes impairment from capacity, with consultee routes where needed.

Clinicians should interpret motor rehabilitation guidelines cautiously when trials exclude or underreport cognition and adapt delivery to support participation.