Table 4. Findings of the systematic reviews.
| Review Intervention focus | n. RCTs included (n. relevant) | Total n. participants | R-AMSTAR quality rating/44 | Time at which outcomes measured | Primary and Secondary Outcomes Beneficial effect +Harmful effect –No significant effect 0 | Narrative synthesis | Meta-analysis | Significant findings | Interpretation |
|---|---|---|---|---|---|---|---|---|---|
| Therapy rehabilitation | |||||||||
| Aziz, 2008 [17] Rehabilitation 1 year post stroke | 5 (5) | 487 | 40 | 3–12 months | 1° ADL / Extended ADL | 0/0 | Inconclusive whether intervention was able to influence any other relevant patient outcome one year after stroke. | ||
| QoL | 0 | ||||||||
| 2° Mood | 0 | ||||||||
| Poor outcome(s) or death | + | Difference in poor outcome or death (51% versus 76%) (95% CI 3% to 48%; P = 0·03). | The only positive finding is based on a single study. | ||||||
| Hoffman, 2010 [18] OT for cognitive impaired | 1 (0) | 33 | 35 | NS | 1 o ADL | 0 | No significant findings to report. | There is a paucity of RCTs evaluating cognitive rehabilitation in stroke survivors as only 1 RCT was identified. | |
| Legg, 2006 [19] OT rehabilitation | 9 (8) | 1258 | 42 | 3–12 months | 1 o ADL | ++ | Improved ADL (SMD 0·18; 95% CI 0·04 to 0·32; P = 0.01) | OT rehabilitation has positive outcomes on personal activities of daily living. | |
| Extended ADL | + | Improved extended ADL (SMD 0·21; 95% CI 0·03 to 0·39; P = 0·02). | |||||||
| QoL | 0 | ||||||||
| 2 o Mood | 0 | ||||||||
| Poor outcome(s) or death | + | Reduction in odds of a poor outcome or death (OR 0·67; 95% CI 0·51 to 0·87; P = 0·003). Reduction in odds of deterioration or death (OR 0·60; 95% CI 0·39 to 0·91; P = 0·02). | |||||||
| OST, 2003 [20] Therapy rehabilitation | 14 (11) | 1617 | 41 | 3–12 months | 1 o ADL | + | Increased ADL scores (SMD 0·14, 95% CI 0·02 to 0·25; P = 0·02). | Both positive outcomes indicate therapy based rehabilitation to have a positive effect on personal activities of daily living. | |
| Extended ADL | ++ | Increased extended ADL scores (SMD 0·17, 95% CI 0·04 to 0·30; P = 0·01). | |||||||
| QoL | 0 | ||||||||
| 2 o Mood / Service use | 0/0 | ||||||||
| Poor outcome(s) or death | ++ | Reduction in the odds of a poor outcome or death (OR 0·72; 95% CI 0·57 to 0·92; P = 0·009). | |||||||
| Poulin, 2012 [21] Therapy rehabilitation for cognitive impairment | 3 (1) | 109 | 32 | NS | 2 o Working memory training Cognitive function | ++ | Working memory training sub-group (chronic) Reduction in cognitive failures (effect size = 0·80; P = 0·005). | All findings are based on a single study so are taken with caution. | |
| 1 o Strategy training Extended ADL | ++ | Strategy training sub-group (chronic). Positive effects on extended ADL (P <·01). Improvement in problem solving self-efficacy was greater for face to- face group compared to self-paced computer assisted training, or online though video conferencing (F = 6·45; P = 0·003). | Strategy training is the only intervention which meets our definition of SM support. The review offers some support for the effectiveness of strategy training on improving extended activities of daily living. | ||||||
| 2 o External compensation Compliance | ++ | External compensation sub-group (chronic) Improved compliance in activities (z = 2·953, P = 0·003) | All RCTs involved individuals in the chronic phase of recovery, highlighting need for research into cognitive rehabilitation at early stages. | ||||||
| Steultjens, 2003 [22] OT rehabilitation | 18 (6) | 1825 | 32 | NS | Comprehensive OT | Comprehensive OT was found to positively affect more outcomes than any of the other sub-groups, and is the only sub-group which meets our SM support definition. The outcomes reported for comprehensive OT are a composite of 6 RCTs. | |||
| 1° ADL / Extended ADL | +/0 | Small but significant effect sizes on ADL (SMD 0·31; 95% CI 0·03 to 0·60). | |||||||
| Community reintegration | 0 | ||||||||
| Cognitive function | |||||||||
| 1 o ADL | 0 | ||||||||
| Training of skills | Isolated OT elements were found to be much less effective than comprehensive OT; only skills training found any beneficial effects and these were based on a single study so must be taken with caution. | ||||||||
| 1 o ADL | +* | Significant effect on ADL in one study (SMD 0·46; 95% CI 0·05 to 0·87) | |||||||
| Extended ADL | +* | Significant effect on extended ADL in another study (SMD 2·29; CI 1·26 to 3·32) | |||||||
| Cognitive vs training of skills. | |||||||||
| 1° ADL / Extended ADL | 0/0 | ||||||||
| 2° Cognitive function | 0 | ||||||||
| Advice about assistive devices. | |||||||||
| 1° QoL | 0 | ||||||||
| No RCTs were found exploring education of family or caregivers by an OT. Whilst education provision is an important role of an OT, it is something that is unlikely to be done in isolation, this may explain the paucity of RCTs in this area. | |||||||||
| Walker, 2004 [23] OT rehabilitation | 8 (8) | 1143 | 35 | End of intervention 1.25–6 months. End of trial 4.5–12 months. | 1° ADL | +* | OR 0·71; 95% CI 0·52 to 0·98 | The duration/intensity of intervention did not mediate the effect on the primary outcome. This review supports OT rehab, demonstrating positive effects on extended ADL and leisure scores. | |
| Extended ADL | +* | WMD 1·30 points; 95% CI 0·47 to 2·13 | The effect on extended ADL varied by age; older patients appeared to benefit more than younger ones (P = 0·01). | ||||||
| Community reintegration | +* | WMD 1·51 points; 95% CI 0·24 to 2·79 | |||||||
| 2° Mood | 0 | ||||||||
| Poor outcome(s) or death | 0 | ||||||||
| OT emphasising ADL | |||||||||
| 1° Extended ADL | +* | WMD 1·61 points; 95% CI 0·72 to 2·49 | |||||||
| Community reintegration | 0 | ||||||||
| OT emphasising leisure | Patients with lower levels of dependency appeared to benefit more in leisure scores (WMD 2·86 points; 95% CI 0·70 to 5·02). | ||||||||
| 1° Extended ADL | 0 | ||||||||
| Community reintegration | +* | WMD 1·96 points; 95% CI 0·27 to 3·66 | |||||||
| Other SM support | |||||||||
| Ellis, 2010 [24] Stroke liaison | 16 (16) | 4759 | 35 | NS | 1° ADL | 0 | No positive overall effects were demonstrated for stroke liaison. | ||
| Extended ADL | 0 | ||||||||
| Community reintegration | 0 | ||||||||
| QoL | 0 | ||||||||
| 2° Mood | 0 | ||||||||
| Poor outcome(s) or death | 0 | ||||||||
| Education and information | |||||||||
| 1° QoL | + | SMD -0·24; 95% CI -0·44 to -0·04; P = 0·02 | |||||||
| Barthel 15–19 | (mild to moderate disability) | ||||||||
| 2° Poor outcome(s) or death | + | Significant reduction in dependence (OR 0·62; 95% CI 0·44 to 0·87; P = 0·006), and death or dependence (OR 0·55; 95% CI 0·38 to 0·81; P = 0·002).Significant subgroup heterogeneity found for the Barthel 15–19 group (Chi2 P < 0·05). | Post-hoc analysis found positive effects for those individuals with mild to moderate disability | ||||||
| Ko, 2010 [25] Patient held medical records | 0 (0) | 0 | 31 | Found no RCTs – no outcomes to report. | Found no RCTs – no outcomes to report. | Found no RCTs – no outcomes to report. | No RCTs were identified which studied the use of patient held medical records in stroke survivors. This highlights an area of potential stroke SM where more primary research is required. | ||
| Korpershoek,2011 [26] Self-efficacy enhancing | 4 (2) | 630 | 24 | 6 and 12 month (Chronic disease SM), NS/NR for others. | Chronic Disease SM Course | Only the chronic disease self-management course definitely met our definition of SM support and that showed positive results on a range on health-related quality of life outcomes. However, the results from this review must be taken with caution as each sub-group represents a single study. | |||
| 1° Self-efficacy | 0 | ||||||||
| Community reintegration | 0 | ||||||||
| QoL | ++ | Significant positive effect on HRQL outcomes including mobility (P < 0.01), self-care (P < 0·001), thinking (P < 0·01), and social roles (P < 0·001). Computer-generated tailored information sub-groupm Anxiety scores changed significantly in favour of control, (95% CI 0·2 to 2·8, P = 0·03). | |||||||
| 2° Mood | 0 | ||||||||
| Lui, 2005 [27] Caregiver problem solving | 6 (6) | 1676 | 24 | 2 weeks- 12 months | 1° ADL | 0 | |||
| Self-efficacy | 0 | ||||||||
| Community reintegration | + | Better patient adjustment at 12 months after stroke (P<0·01). Improvement of social outcome in patients with mild disability at 6 months (P = 0·03). | The reported positive results represent only 1 study each. (Only 3 of 6 RCTs reported outcomes for stroke survivors). | ||||||
| 2° Mood | 0 | ||||||||
| Rae-Grant, 2011 [28] SM | 0 (0) | 0 | 27 | Found no RCTs | Found no RCTs – no outcomes to report. | Found no RCTs – no outcomes to report. | There is an absence of RCTs explicitly investigating stroke self-management. | ||
| Smith, 2008 [29] Information provision | 17 (9) | 2831 | 40 | 1 week-1 year | 1° ADL | 0 | . | We take active, but not passive, information provision to be SM support. | |
| Community reintegration | 0 | ||||||||
| QoL | 0 | ||||||||
| 2° Mood | ++ | Clinically small benefit of information provision on depression (WMD -0·52; 95% CI, 0·93 to -0·10; P = 0·01) Active information provision significantly more effective than passive information for depression (P < 0·02 for all the trials), and anxiety (P < 0·05 for trials reporting dichotomous data, P < 0·01 for trials reporting continuous data) | This review provides evidence that active information has a positive impact on anxiety and depression in stroke survivors | ||||||
| Service use / Compliance | 0/0 | ||||||||
| Poor outcome(s) or death | 0 | ||||||||
0 No evidence of effect (P> 0·05) + Some evidence of effect in favour of intervention/control (0·05 ≥P> 0·01) ++ Strong evidence of effect in favour of intervention/control (0·01≥P> 0·001)
* No p values provided, there is at least some evidence of effect, but may underestimate true effect size