Stroke, mindfulness and meditation
A literature review
Dr Ian Gawler OAM, BVSc, MCounsHS. November 2020.

The challenge

What evidence is there mindfulness and meditation can have therapeutic benefits for those affected by stroke? Are people affected by stroke capable of practicing mindfulness and meditation? Even more, what evidence is there an online program will be useful?

While this is an emerging field of research, already there is some good evidence for mindfulness and meditation – including on-line programs - facilitating improvements in both coping and recovery; and that carers can receive significant benefit.

1. Anxiety and depression

a) The scale of the problem amongst those affected by stroke

The prevalence of depression is reported to be very high among stroke survivors and has been associated with adverse clinical outcomes.

A meta-analysis published in 2005 reported a pooled estimate of 33% for the prevalence of depression in stroke survivors (i). A multi-national study of 220 patients observed that the prevalence of depression remained as high as 33% for up to 5 years post stroke (ii). In addition, a review assessing post-stroke mortality reported increased odds of mortality for a period of 2 to 5 years among patients with depressive symptoms based on findings from 13 studies including 59,598 patients with stroke (iii). Previous research has suggested that the prevalence of depression and anxiety among carers is comparable to the observed prevalence levels among stroke survivors, and directly related to the severity of stroke (iv – vi). In addition, there is also evidence that stroke survivors and their carers mutually influenced each other’s emotional state (vii – viii).

i) Hackett ML, Yapa C, Parag V, Anderson CS. Frequency of depression after stroke: a systematic review of observational studies. Stroke. 2005;36:1330–1340. https://pubmed.ncbi.nlm.nih.gov/15879342/

ii) Lincoln NB, Brinkmann N, Cunningham S, Dejaeger E, De Weerdt W, Jenni W, et al. Anxiety and depression after stroke: a 5 year follow-up. Disabil Rehabil. 2013;35:140–145.

iii) Bartoli F, Lillia N, Lax A, Crocamo C, Mantero V, Carrà G, et al. Depression after stroke and risk of mortality: a systematic review and meta-analysis. Stroke Res Treat. 2013;2013:862978.

iv) Berg A, Palomaki H, Lonnqvist J, Lehtihalmes M, Kaste M. Depression among caregivers of stroke survivors. Stroke [Internet] 2005;36:639–643.

v) Opara JA, Jaracz K. Quality of life of post-stroke patients and their caregivers. J Med Life. 2010;3:216–220.

vi) Denno MS, Gillard PJ, Graham GD, DiBonaventura MD, Goren A, Varon SF, et al. Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity. Arch Phys Med Rehabil [Internet] 2013;94:1731–1736

vii) McCarthy MJ, Lyons KS, Powers LE. Expanding poststroke depression research: movement toward a dyadic perspective. Top Stroke Rehabil [Internet] 2011;18:450–460.

viii) Godwin KM, Ostwald SK, Cron SG, Wasserman J. Long-term health-related quality of life of stroke survivors and their spousal caregivers. J Neurosci Nurs [Internet] 2013;45:147–154.


b) Mindfulness and meditation relieve anxiety and depression

Several systematic reviews and meta-analyses support the use of mindfulness-based interventions (MBIs) (largely derived from MBSR) in helping people with long-term conditions (LTCs) to cope better with improvements in symptoms of anxiety and depression.

Here are two…

i) Bohlmeijer E, Prenger R, Taal E, Cuijpers P. The effects of Mindfulness-Based Stress Reduction therapy on mental health of adults with a chronic medical disease: a meta-analysis. J Psychosom Res. 2010;68:539–544.

ii) Hofmann SG, Sawyer AT, Witt AA, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta-analytic review. J Consult Clin Psychol. 2010;78:169–183.


2. Mindfulness and meditation’s specific influence on stroke outcomes

A recent systematic review of the benefits of MBIs among patients with stroke, including four studies and 160 participants in total, concluded that a range of benefits may be derived from MBIs in this population.

Lawrence M, Booth J, Mercer S, Crawford E. A systematic review of the benefits of mindfulness-based interventions following transient ischemic attack and stroke. Int J Stroke. 2013;8:465–474.


Another systematic review and critical appraisal of the evidence on the effectiveness of behavioural therapies such as yoga and mindfulness practices for stroke rehabilitation examined 5 randomized controlled clinical trials and 4 single case studies. Additionally, one qualitative research study was identified. Studies reported positive results, including improvements in cognition, mood, and balance and reductions in stress. The authors concluded yoga and mindfulness could be clinically valuable self-administered intervention options for stroke rehabilitation.

Lazaridou A, Philbrook P, Tzika AA. Yoga and mindfulness as therapeutic interventions for stroke rehabilitation: a systematic review. Evid Based Complement Alternat Med. 2013;2013:357108.


3. Can people affected by stroke actually practice mindfulness and meditation?

Clinical experience says yes, however, recently a small study did examine the feasibility of an adapted 2-week mindfulness meditation protocol for chronic stroke survivors. In addition, preliminary effects of this adapted intervention on spasticity and quality of life in individuals after stroke were explored. Exploratory preliminary analyses showed statistically significant improvements in spasticity, along with improvements in quality of life measures for Energy, Personality, and Work/Productivity.

Wathugala M, Saldana D, Juliano JM, Chan J, Liew SL. Mindfulness Meditation Effects on Poststroke Spasticity: A Feasibility Study. J Evid Based Integr Med. 2019 Jan-Dec;24:2515690X19855941.


4. Online programs and their benefits – a meta-analysis

The aim of this meta-analysis of 15 randomised controlled studies was to estimate the overall effects of online MBIs on mental health. Results showed that online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness. The largest effect was found for stress, with a moderate effect size.

For stress and mindfulness, analysis demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, effect sizes for stress were significantly moderated by the number of intervention sessions.

The researchers concluded their findings indicate online MBIs have potential to contribute to improving mental health outcomes.

Spijkerman MPJ et al. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review Vol 45, 2016, 102-114.


5. Conclusion

There is a solid evidence base for mindfulness and meditation being used to help people affected by stroke (including their carers). These interventions can reduce the associated symptoms of stroke such as stress, anxiety and depression, as well as assist in recovery.

Also, there is good evidence online mindfulness - based programs have positive benefits and that these benefits are increased with the support of an on-line guide or mentor. Further, the evidence concludes that increasing the number of guided sessions increases the measured benefits.