Stroke rehabilitation is composed of two broad types of interventions: restorative and adaptive.1 Therapists use restorative interventions with the goal of correcting stroke-related impairment. In this way, restorative approaches focus on normalizing body structures and function. Therapists use adaptive interventions to optimize patients’ abilities to perform valued activities despite existing impairment, generally through changes to the environment or the activity. When used in the patient's home or community, adaptive approaches focus on participation, which is the accomplishment of complex activities within real-life contexts.2
Current stroke rehabilitation best practice guidelines recommend specific restorative interventions, such as constraint-induced movement therapy3 and cognitive retraining.4 However, there are fewer and only vague recommendations with regards to adaptive interventions.5 Stroke rehabilitation guidelines recommend that therapists work collaboratively with patients to identify ways to improve current functioning in home or community activities. Yet, these guidelines do not provide guidance regarding which adaptive interventions are most effective; in fact, they do not refer to any specific adaptive approach.6 This may give the impression that specific participation-focused approaches do not exist or have not been evaluated, which is not the case.
Research groups across the globe have developed specific interventions for improving participation after stroke through adaptive means. Many of these interventions are explicitly or implicitly based on a metacognitive or a self-management approach.
Interventions based on a metacognitive approach help patients learn to think about the problems they are confronting, propose ways to solve the problem, test out these solutions, and reflect on the results of these experiments to further refine performance. The proposed mechanism of action is being able to think about one's performance in a way that produces useful solutions to meet specific goals. That is, patients develop problem-solving strategies that can be applied to both current and future participation challenges.7 For example, the intervention Cognitive Orientation to Daily Occupation (CO-OP) is based on a metacognitive approach.8
Interventions based on a self-management approach assist patients to live well with chronic illness or disability through developing a better understanding of their condition and how to effectively manage it.9 The proposed mechanism of action is improved self-efficacy, that is confidence in one's ability to seek out and enact solutions to challenges that arise in living with a chronic health condition. Bridges to Self-Management is an example of an intervention that includes a self-management component.10
While many researchers report basing their intervention on a metacognitive or self-management approach, there is built-in overlap, as both approaches contain elements of goal setting and action planning by patients. Furthermore, some adaptive interventions claim a basis in both metacognitive and self-management approaches, such as the Occupational Performance Coaching (OPC).11 It is also probable that other interventions contain one or more elements of each approach.
A preliminary search using the terms “stroke,” “participation,” “metacognitive,” and “self-management” produced over 30 different interventions. Most have been examined in single trials by researchers, or by single research groups. The result is a diverse array of potentially similar adaptive interventions, with no clear picture as to the extent to which their theoretical bases or components overlap. When considering self-management, approach-based interventions in particular, Fryer et al.12 noted that existing variability in the types of programs and their delivery methods may impact participation outcomes in a way researchers do not yet understand. This is potentially true of metacognitive approach–based interventions as well.
Stroke rehabilitation procedures are best conceptualized as complex interventions.13 Progress in the science of complex interventions cannot be made without elucidating theoretical principles, hypothesized methods of action, associated treatment elements, and anticipated outcomes.14 A catalogue of current adaptive interventions, including a comparison of their explicit or implicit theory and components, methods of delivery, and anticipated outcomes would therefore be helpful for practitioners and researchers. Such a catalog would help clinicians and scientists i) retrieve information about specific interventions; ii) recognize underlying theoretical bases of these interventions; iii) critique interventions based on the agreement between theoretical foundations and elements; iv) compare and contrast interventions according to underlying theory and elements; and v) group diverse interventions into meaningful categories for the purpose of systematic review of outcomes and future research.
The objective of this scoping review is to develop a document that catalogs adaptive stroke rehabilitation interventions targeting participation as an outcome. This review will describe explicit and implicit theories underlying participation-focused adaptive interventions and relate their theoretical aspects to the type of approach used. Given the range and diversity of such interventions, it is necessary to begin by targeting the search to a limited number of over-arching strategies. Therefore, the authors will structure their search around interventions based on the two main adaptive approaches: self-management and metacognitive approaches.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Database of Systematic Reviews and Implementation Reports was conducted and resulted in the discovery of one systematic review currently underway and four completed reviews with connections to the proposed review. However, none of these studies specifically address the authors’ aims.
Nott and colleagues15 have registered a protocol for a systematic review to determine the effectiveness of metacognitive approaches for improving participation after acquired brain impairment, including stroke. The protocol is not designed to examine explicit or implicit theory behind or elements within approaches, as our review is intended to do. In addition, our review will examine interventions based on self-management, as well as those based on metacognitive approaches.
With regards to previous reviews, a systematic review16 and a Cochrane Review12 were published based on interventions incorporating a self-management approach with the aim of improving participation after stroke. These studies overlap with this review in the identification of interventions modeled on a self-management approach focusing on improving participation. However, our study builds on both through inclusion of a wider variety of studies (that is, not exclusively randomized controlled trials), a greater focus on elements of each intervention, and examination of interventions based on a metacognitive approach.
Two earlier studies also provided systematic reviews of self-management interventions on participation outcomes.17,18 This study will build on these through updated literature, a closer examination of intervention elements, and the inclusion of interventions based on a metacognitive approach.
Within publications on interventions that incorporate metacognition and self-management, the elements and theoretical underpinning used in the interventions may vary and overlap. Such variation produces interventions that may straddle both approaches. Our examination of different elements and underlying theories within these approaches will help disentangle the effects of these interventions in adults who have had a stroke. The authors aim to outline the most appropriate program formats that can be delivered in various contexts.
What interventions based on a metacognitive or self-management approach with the goal of improving participation among adult stroke survivors have been documented in the research literature?
- i) What theories do researchers explicitly or implicitly evoke in describing these interventions?
- ii) What elements do these interventions include?
- iii) What outcomes, in addition to participation, are targeted?
- iv) Are these elements and targeted outcomes consistent with the theories posited?
- v) How might these interventions be logically grouped, according to underlying theory?
- vi) What level of testing have these interventions and groups of interventions been subject to?
This review will include studies describing research on stroke rehabilitation interventions that use metacognitive or self-management approaches, with the goal of improving participation among adults who have experienced a stroke.
This review will consider studies that explore stroke rehabilitation interventions based on metacognitive or self-management approaches with implicit or explicit underlying theories. This represents a broad set of interventions, with multiple names, different theoretical underpinnings, and diverse elements. A scoping review will begin to determine logical groupings under which these interventions can be better compared and refined. The interventions must seek to improve participation globally or specifically, and studies must measure this concept. Measures examining either a generic set of complex activities, or specific activities identified by the stroke survivors will be included. The interventions must contain at least one element of metacognitive strategy training or self-management, including goal setting, strategy teaching, strategy development, problem solving, attempting the activity, reflecting on experiences of attempting the activity, emotional support, and education. There will be no restrictions to modes of delivery, intervention duration, or health care provider background.
The interventions to be included in this review can be delivered in institutional and non-institutional settings, including hospitals, public or private community rehabilitation clinics, long-term care facilities, and homecare. Eligible studies will not be limited to any geographic location.
Types of sources
This scoping review will consider quantitative, qualitative, and mixed methods study designs for inclusion. In addition, systematic and scoping reviews addressing the population, concept, and context previously described will be included. Studies available in both English and French in the following databases will be reviewed: JBI Evidence-Based Practice Database (1998–2020), MEDLINE via Ovid (1946–2020), Embase via Ovid (1947–2020), CINAHL via EBSCOHost (1937–2020), PsycINFO via Ovid (1806–2020), OTSeeker (2003–2020), and PEDro (1999–2020). Conference proceedings in Embase via Ovid (1947–2020) will be considered as well as the reference lists and citations of studies selected for full text review.
Studies will be excluded if the intervention is focused on providing generic stroke education or solely on decreasing impairment (eg improving cognition). Papers describing chronic disease self-management interventions aimed at improving adherence to medical management (including decreasing stroke risk factors) will also not be considered. Studies with samples that include people experiencing non-stroke-related conditions, as well as papers written in languages other than English or French will be excluded.
The proposed scoping review will be conducted in accordance with the JBI methodology.19
The search strategy will aim to locate all eligible studies regardless of the year of publication. Based on the text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, a full search strategy for MEDLINE was developed (see Appendix I). Terms related to the population (eg stroke, cerebrovascular accident, adult), the concepts (eg metacognition, self-management), and other keywords and index terms will be adapted for each database, considering the MeSH and key term variations. Databases will be consulted again before final analyses if the review process exceeds six months in duration. This strategy will ensure the identification of any recent studies meeting the inclusion criteria.
The search of this scoping review will include JBI Evidence-Based Practice Database, MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOHost), and PsycINFO (Ovid) databases to identify studies on the topic. Supplementary searches will also be conducted to search for trials in OTSeeker, a database that contains abstracts of systematic reviews, randomized controlled trials, and other resources relevant to occupational therapy interventions, as well as Physiotherapy Evidence Database (PEDro), a database of randomized trials, systematic reviews, and clinical practice guidelines in physiotherapy. Conference proceedings located in Embase (Ovid) will be examined, as will the reference lists and citations of studies selected for full text review to capture any additional studies.
Studies will be selected according to a three-step process that will encompass i) managing search results and removing duplicates; ii) title and abstract screening; and iii) full text screening. LS will run the full search to identify records that will be collated and uploaded into the web-based management software Covidence (Veritas Health Innovation, Melbourne, Australia), with duplicates removed. Titles and abstracts will then be screened by two independent reviewers (ME and DK) for assessment against the inclusion criteria for the review. In the final step, potentially relevant papers will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers (ME and PD).
Reasons for exclusion of full text papers that do not meet the inclusion criteria will be recorded and reported in the scoping review. A third reviewer (PM) will assess any discrepancies and resolve any disagreements that arise between the reviewers at each stage of the selection process. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.20
Data will be extracted from papers included in the scoping review by two independent reviewers (NG-J and AC) using a spreadsheet developed by the reviewers according to the items from the TIDieR checklist21 as the data extraction tool. The data extracted will consist of the specific details from the included studies regarding the population, concept, context, methods, and key findings relevant to the review objectives, according to the domains of the extraction tool. The data extraction tool will be modified and revised as necessary during the process of extracting data from each included paper. Modifications will be detailed in the full scoping review. Any disagreements that arise between the reviewers will be resolved by a third reviewer (DK). Authors of papers will be contacted to request missing or additional data, where required.
The extracted data will be presented in tabular form along with a narrative summary in a manner that aligns with the objectives and scope of this review. To answer the general research question (What interventions based on a metacognitive or self-management approach with the goal of improving participation among adult stroke survivors have been documented in the research literature?), a table of all named interventions will be developed. To answer sub-question i) (What theories do researchers explicitly or implicitly evoke in describing these interventions?), a row in the table for underlying explicit or implicit theories evoked will be included. Where possible, interventions will be grouped in the table by underlying theory to respond to sub-question v) (How might these interventions be logically grouped, according to underlying theory?). This table will include a tally of randomized controlled trials, non-randomized controlled trials, and other studies for each intervention, along with total number of participants, in response to sub-question vi) (What level of testing have these interventions and groups of interventions been subject to?). Responses to sub-questions ii) (What elements do these interventions include?) and iii) (What outcomes, in addition to participation, are targeted?) will be represented by a graph. The authors will note consistencies and inconsistencies between theories, elements, and targeted outcomes in the text to respond to sub-question iv) (Are these elements and targeted outcomes consistent with the theories posited?). Such data presentation may be further refined as the contents of included studies are analyzed.22
Appendix I: Search strategy
Search on April 16, 2020 and 436 hits were received.
- 1. exp Stroke/
- 2. (poststroke∗ or post-stroke∗ or stroke∗).tw.
- 3. (cerebrovascular adj2 accident∗).tw.
- 4. cva∗.tw.
- 5. apoplex∗.tw.
- 6. ((brain∗ or cerebral∗ or brainstem∗ or brain stem∗ or subcortical∗ or vascular∗) adj4 (infarct∗ or accident∗ or occlus∗ or emboli∗ or thrombo∗ or isch?emi∗ or bleed∗ or h#emorrhage∗ or h#matoma∗)).tw.
- 7. (lacunar adj3 (infarct∗ or syndrome∗ or accident∗)).tw.
- 8. ((benedict or weber or claude or foville or millardgublar) adj2 (syndrome∗ or disorder∗ or disease∗)).tw.
- 9. top of the basilar syndrome∗.tw.
- 10. or/1-9
- 11. Metacognition/
- 12. metacogn∗.tw.
- 13. meta cogn∗.tw.
- 14. metaemot∗.tw.
- 15. meta emot∗.tw.
- 16. metamemor∗.tw.
- 17. meta memor∗.tw.
- 18. Self-Management/
- 19. self manag∗.tw.
- 20. selfmanag∗.tw.
- 21. exp Problem Solving/
- 22. (problem adj2 solv∗ adj2 therap∗).tw.
- 23. Cognitive Orientation to daily Occupational Performance.tw.
- 24. (CO?OP adj2 approach).tw.
- 25. OPC-stroke.tw.
- 26. occupational performance coaching.tw.
- 27. bridges self-management.tw.
- 28. (goal∗ adj2 manag∗).tw.
- 29. ASPIRE.tw.
- 30. restore4stroke.mp.
- 31. brainz.tw.
- 32. or/11-31
- 33. 10 and 32
- 34. exp Adult/ or (adult or adults or adulthood or middle age or middle aged or elderly or senior or seniors or man or men or woman or women).tw.
- 35. 33 and 34
1. Cumberland Consensus Working Group, Cheeran B, Cohen L, Dobkin B, Ford G, Greenwood R, et al. The future of restorative neurosciences in stroke: driving the translational research pipeline from basic science to rehabilitation
of people after stroke. Neurorehabil Neural Repair
2009; 23 (2):97–107.
2. World Health Organization. International Classification of Functioning, Disability and Health (ICF) [internet]. 2001 [cited 31 Aug 2019]. Available from: https://apps.who.int/iris/bitstream/handle/10665/42407/9241545429.pdf;jsessionid=10981544C9DA5FFECBF903FB3862EE0E
3. Etoom M, Hawamdeh M, Hawamdeh Z, Alwardat M, Giordani L, Bacciu S, et al. Constraint-induced movement therapy as a rehabilitation
intervention for upper extremity in stroke patients: systematic review and meta-analysis. Int J Rehabil Res
2016; 39 (3):197–210.
4. Rogers JM, Foord R, Stolwyk RJ, Wong D, Wilson PH. General and domain-specific effectiveness of cognitive remediation after stroke: systematic literature review and meta-analysis. Neuropsychol Rev
2018; 28 (3):285–309.
5. Egan MY, Laliberté-Rudman D, Rutkowski N, Lanoix M, Meyer M, McEwen S, et al. The implications of the Canadian stroke best practice recommendations for design and allocation of rehabilitation
after hospital discharge: a problematization. Disabil Rehabil
2019. 1–13 [epub ahead of print].
6. Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S. Canadian stroke best practice recommendations: Stroke rehabilitation
practice guidelines, update 2015. Int J Stroke
2016; 11 (4):459–484.
7. Missiuna C, Mandich AD, Polatajko HJ, Malloy-Miller T. Cognitive orientation to daily occupational performance (CO-OP) part I-theoretical foundations. Phys Occup Ther Pediatr
2001; 20 (2–3):69–81.
8. Polatajko HJ, McEwen SE, Ryan JD, Baum CM. Pilot randomized controlled trial investigating cognitive strategy use to improve goal performance after stroke. Am J Occup Ther
2012; 66 (1):104–109.
9. Barlow J, Sturt J, Hearnshaw H. Self-management interventions for people with chronic conditions in primary care: examples from arthritis, asthma and diabetes. Health Educ J
10. McKenna S, Jones F, Glenfield P, Lennon S. Bridges self-management program for people with stroke in the community: a feasibility randomized controlled trial. Int J Stroke
2015; 10 (5):697–704.
11. Kessler D, Egan M, Dubouloz CJ, McEwen S, Graham FP. Occupational performance coaching for stroke survivors: A pilot randomized controlled trial. Am J Occup Ther
2017; 71 (3):1–7.
12. Fryer CE, Luker JA, McDonnell MN, Hillier SL. Self-management programs for quality of life in people with stroke. Cochrane Database Syst Rev
13. Bernhardt J, Borschmann K, Boyd L, Thomas Carmichael S, Corbett D, Cramer SC, et al. Moving rehabilitation
research forward: developing consensus statements for rehabilitation
and recovery research. Int J Stroke
2016; 11 (4):454–458.
14. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ
15. Nott M, Cuming T, Barden H, Chapparo C, Ranka J. Effectiveness of metacognitive strategy training for enhancing the occupational outcomes of adults with acquired brain impairment. PROSPERO: International prospective register of systematic reviews
16. Parke HL, Epiphaniou E, Pearce G, Taylor SJ, Sheikh A, Griffiths CJ, et al. Self-management support interventions for stroke survivors: a systematic meta-review. PLoS One
2015; 10 (7):e0131448.
17. Lo SHS, Chang AM, Chau JPC, Gardner G. Theory-based self-management programs for promoting recovery in community-dwelling stroke survivors: a systematic review. JBI Database System Rev Implement Rep
2013; 11 (12):157–215.
18. Jones F, Riazi A. Self-efficacy and self-management after stroke: a systematic review. Disabil Rehabil
2011; 33 (10):797–810.
19. Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Chapter 11: Scoping Reviews. JBI Reviewer's Manual [Internet]. Adelaide: JBI; 2017 [cited 21 Aug 2019]. Available from: https://reviewersmanual.joannabriggs.org/
20. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev
21. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Senior DM, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ Res Methods Report
22. Khalil H, Peters M, Godfrey CM, McInerney P, Soares CB, Parker D. An evidence-based approach to scoping reviews. Worldviews Evid Based Nurs
2016; 13 (2):118–123.