Why Stroke Recovery Might Start With Your Brain—Not Your Legs

Stroke survivors often struggle with thinking, memory, and problem-solving after their event, yet most rehabilitation programs focus on physical recovery first. A groundbreaking study from the Medical University of South Carolina (MUSC) shows that addressing cognitive challenges before—or alongside—physical therapy could help patients recover independence faster and more completely.

Why Cognitive Problems After Stroke Get Overlooked

When someone has a stroke, the immediate focus is usually on restoring physical abilities: walking, moving arms, regaining sensation. But cognitive impairments—problems with thinking, memory, attention, and problem-solving—affect up to 70% of stroke survivors and often go unaddressed in traditional rehabilitation programs. These mental challenges can actually prevent patients from benefiting fully from physical therapy, yet they're rarely treated as a priority.

"Cognitive and motor impairments go hand in hand and really affect real-life function. Yet they're often treated separately," explains Dr. Stephanie Aghamoosa, a clinical neuropsychologist at MUSC who led the research.

What Is COG-OT and How Does It Work?

MUSC researchers developed a new treatment approach called COG-OT—combining cognitive rehabilitation with occupational therapy—designed to build a strong foundation for stroke recovery. The program is delivered entirely through video visits in patients' homes, making it accessible to people in rural areas who might otherwise need to travel hours for rehabilitation.

The cognitive portion includes four brief one-on-one sessions focused on the thinking skills most commonly affected by stroke:

• Attention: The ability to focus and concentrate on tasks without distraction
• Memory: Recalling information needed for daily activities like remembering appointments or where items are stored
• Organization: Planning and structuring tasks in a logical sequence
• Problem-solving: Working through challenges and finding solutions independently

After these cognitive sessions, occupational therapists help patients apply these newly strengthened thinking skills directly to everyday activities at home—cooking, doing laundry, managing medications, or maintaining a calendar. This real-world approach is far more practical than traditional clinic-based therapy.

How Is COG-OT Personalized for Each Patient?

One key strength of this approach is flexibility. "A central feature of COG-OT is that it can be adapted and personalized," says Dr. Aghamoosa. If a patient doesn't have memory problems, therapists skip those sessions and focus instead on areas where the patient struggles most. Someone with significant problem-solving difficulties gets more intensive work in that area, while someone with mild attention issues might need less support there.

Importantly, the MUSC team intentionally redesigned their program to include stroke survivors with aphasia—a language disorder that affects speaking, understanding speech, reading, and writing. Many cognitive rehabilitation studies exclude these patients, but the MUSC researchers recognized that aphasia doesn't affect intelligence and shouldn't exclude people from cognitive therapy.

What Did the Research Show?

In the Phase 1 feasibility study, published in the journal Brain Sciences, the results were promising. The treatment was easy to deliver, had very low dropout rates, and participants gave it favorable reviews. "Our main findings show that this treatment is feasible and highly acceptable," Dr. Aghamoosa explains. "People liked it, stayed engaged and used the strategies in their daily lives".

Because therapy happens in patients' homes rather than clinical settings, therapists can address both cognitive and physical challenges in realistic environments where everyday distractions—phone calls, interruptions, fatigue—actually occur. This matters because how someone functions in a quiet clinic often differs from how they function at home.

What's Next for Stroke Recovery?

The MUSC team plans to conduct a larger Phase 2 trial to test how well the COG-OT treatment improves actual recovery outcomes. They're also exploring whether this approach could be adapted for other conditions involving both cognitive and physical challenges, such as aging-related decline.

Meanwhile, other stroke research is revealing additional insights about recovery. University of Cincinnati researchers presented findings at the International Stroke Conference 2026 showing that certain stroke symptoms—particularly leg weakness or walking difficulties—are stronger predictors of long-term disability than others. This information could help doctors decide which patients need aggressive early treatment and which might do well with less intensive interventions.

Another UC study found that approximately one in six stroke survivors has "silent" swallowing problems—real difficulty protecting their airway or clearing food and liquid without feeling any symptoms. These patients face risks of pneumonia, dehydration, and poor nutrition if the problem goes undetected, highlighting the importance of thorough post-stroke evaluation beyond what patients report feeling.

"This approach to stroke recovery is building upon decades of work, innovating in a way that brings it all together to have the best impact for people," says Dr. Aghamoosa. For the roughly 795,000 Americans who have a stroke each year, this shift toward addressing the whole person—not just physical symptoms—could mean the difference between partial recovery and genuine independence.