Self-management interventions to improve mobility after stroke: an integrative review

Figures & data

Table 1. Summary table of the reviewed studies.

Study/Country/Design	Participants	Interventions	Theoretical frameworks/SM strategies	Outcomes	Results	Methodological quality
Baskett et al. [27] New ZealandRCT	N = 100 (mean age 71.7 (IG) and 67.8 (CG) in yrs). Stroke survivors after discharge. Subacute stage.	IG: OT and PT visit once a week and exercises prescribed. Encouraged to exercise several times a day. Therapists guided the self-directed therapy. CG: Outpatient or day hospital therapyDuration: 18 months. Format: One-to-one. Delivered by: PT/OT at home for the intervention group.	TF: Unclear. SM strategies: Goal setting/ action planning/self-monitoring.	Gait speed, Limb function, Activities of daily living, Time with therapists, Mood of subjects and caregivers, Anticipated outcomes at entry, Perceived outcome at exit.	No statistical differences between the control and experimental groups in any outcome measures.	High risk of bias (CRoB). No blinding. Used surrogate quality of life measures in screening for mood disorders.
Broetz & Birbaumer [28] GermanyCase report	54-year-old male who suffered cerebral bleeding with left hemiparesis 25 years ago (chronic stage).	Over the 18-month period the programme included: Daily intensive exercises × 1 week. One-hour sessions/ week. Goal-setting. Self-control cues for exercises Supervision and feedback after successful trials. Intensive training week repeated at 6 months and 12 months. Duration: 18 months. Format: One-to-one. Delivered by: Physiotherapist.	TF: Behavioural physiotherapy incorporating motor learning. SM strategies: Goal setting, Motivation, Supervision, Feedback and Reward.	Walking capacity, Goal attainment, andChange of symptoms.	Rhythmic walking improved from 74 steps/ minute to 112 steps/minute, Walking speed increased from 8.65 s to 6.48 s, and Running for 80 M.	High risk of bias (CASP). Case report of only one participant, high possibility of selection, performance, and detection bias.
Chumbler et al. [29] USAA prospective, single-blinded RCT	N = 48(mean age 67.1–67.7 yrs). Participants with ischemic or haemorrhagic stroke. Subacute stage. Discharged to the community. Not cognitively impaired. Able to follow a 3-step command. Discharge motor Functional Independence Measure (FIM) score (18–88).	IG: STeleR intervention: 3 home visits, 5 telephone calls, In-home messaging device for instructions on functionally based exercises and adaptive strategies. CG: usual care Duration: 3 monthsFormat: One-to-one. Delivered by: Therapist via home visit or telephone calls	TF: The Verbrugge and Jette’s model for the disablement process. SM strategies: Goal settingAction planningSelf-monitoring.	Telephone Version of Functional Independence Measure Function scales of the Late-Life Function and Disability Instrument (LLFDI).	The outcomes improved at 6 months for the STeleR group and declined for the usual care group4 of the 5 (LLFDI) component subscales (P0.05),	Low risk of bias (CRoB). Sample had majority males and wasn't inclusive for stroke population.
Dean et al. [30] UKMixed methods study	N = 45 (mean age 70 (IG) and 71 (CG) in yrs). Stroke survivors with mobility issues. Discharged from rehabilitation services at least 1 month before. Subacute and chronic stages. Possessing sufficient physical, cognitive, and communication ability.	IG: ReTrain which included: A one to one to 1 session followed by ten, twice-weekly group classes, Cardiovascular and strength work, Self-management strategies, Functional activities, Goal setting, and Bespoke home-based training programme. CG: Exercise after stroke advice booklet plus usual care. Duration: 3 monthsFormat: Group and one-to-one. Delivered by: Personal trainers on the UK Register of Exercise Professionals.	TF: Action for Rehabilitation following Neurological Injury (ARNI). SM strategies: EducationGoal settingAction planningProblem-solvingSelf-monitoringGroup and social support.	Primary outcomes: Rivermead Mobility Index, Timed Up and Go, Modified Patient-Specific Functional Scale, 7-day objective physical activity levels using wrist-worn accelerometer, and Physical activity diary. Secondary outcomes: Stroke Self-Efficacy Questionnaire, Fatigue Assessment Scale, EuroQol- 5 Dimension (EQ-5D-5L).	The trial was not powered to detect differences in any outcomes between trial arms or over time.	Low risk of bias (MMAT). It failed to identify a clearprimary outcome for a definitive RCT. Small sample that did not have a wide age range or ethnic diversity. This was a pilot study, not designed to demonstrate generalisability.
DePaul et al. [31] CanadaMixed methods study	N = 10 (mean age 62.3; SD 11.7 years). Inpatient stroke rehabilitation Acute and subacute stages. Functional Ambulation Classification scores (2-4). Functional Independent Measure ≥ 40.	IMPACT: Starts in the hospital and continues after discharge. Usual therapyPhysiotherapy −8 sessions × 2 weeks Duration: 14 days. Format: One-to-one. Delivered by a trained PT.	TF: Social cognition theory and Self-determination theory. SM strategies: Education and professional supportGoal setting Decision makingAaction planningSelf-monitoring and Feedback.	6 min Walking Test, 5-meter Walk Test, Functional Independence Measure (total and motor), Berg Balance Test, Functional Ambulation Category, Chedoke-McMaster Stroke Assessment (CMSA leg and foot). Therapists’ and patients’ perceptions were qualitatively collected.	Gait speed improved by an average of 0.32 m/s (SD 0.27 m/s) on 5-m walk test. 6MWT improved on an average of 85.0 m (SD 64.0) over the 2-week intervention period. All patients indicated that the programme helped them increase their activity and indicated they would continue to practice walking-related activities beyond the coaching period.	High risk of bias (MMAT). Small and inconclusive sample. Single therapist and single setting. Single-group study design. Not powered to detect outcomes changes. Amount of training wasn't accurately reported across all participants.
Ezeugwu & Manns [32] CanadaSingle group, longitudinal intervention study	N = 34 (mean age = 64.6 yrs). Within 2 weeks of discharge from inpatient facilities. Subacute stage. Able to stand up from a chair. Walk at least 5 meters with or without gait aids. Able to understand 2-step commands.	STand Up Frequently From Stroke (STUFFS) Sedentary time was interrupted with upright activities (standing and walking) at home and in the community. A motivational wrist-worn activity monitor was used throughout the intervention. Duration: 8-weeks Format: One-to-one. Delivered by PT at home.	TF: Social cognitive theory. SM strategies: Action planningSelf-monitoring.	Chedoke-McMaster Stroke Assessment (CMSA) for leg and foot, 5-meter walk test, Timed Up and Go, Sedentary behaviour and physical activity (time sedentary, standing, and stepping, the number of steps, sit-to-stand transitions) were measured using the activPAL, The Montreal Cognitive Assessment (MoCA), Stroke Impact Scale, and Self-Efficacy for Exercise Scale Outcomes were assessed with 1-week baseline, 8-week intervention, and 8-week follow-up.	Sedentary time decreased by 54.213.7 min/day (p < .01) at post intervention and 26.814.0 min/day (p < 0.07) at follow-up, Significant improvements in walking speed, (p < .05). The number of steps and time spent stepping were not statistically different across both time periods.	Some concerns about risk of bias (CASP). The sample was limited to specific stroke population. No control group. The duration of the intervention was too short to achieve change in behaviour.
Haworth et al. [33] UKAn exploratory, single blind RCT	N = 44 ( mean age 40.9 (IG) and 42.3 (CG) in yrs). Patients with neurological conditions including stroke. Within 4 weeks of discharge from in-patient care. Subacute stage. Able to carry out exercise independently. Sit and ransfer independently.	IG: Exercise and education programme twice weekly over four weeks. Education involved lectures about the benefits of exercises and self-management mobility, strength and balance exercises CG: Standard follow-up care including medical review clinics and outpatient therapy. Duration: 4 weeks. Format: Group.Delivered by: by research therapist at specialist neurosciences centre.	TF: Self-efficacy. SM strategies: EducationGroup intervention.	Primary outcomes: Exercise Efficacy Scale and Human Activity Profile. Secondary outcomes: 10-metre timed walkShort Form 36 Health Survey, Hospital Anxiety and Depression Scale, UWIST Mood Adjective Checklist, Motricity Index, Frenchay Arm Test, Rivermead Mobility Index, and a visual analogue scale. Data were collected at baseline and at 6, 12 and 24 weeks.	At 6 weeks, significant improvements in exercise efficacy in the treatment group (p = 0.001). Moderate improvements inactivity levels were noted for both study groups with no between-group differences. No significant improvements in SF 36 ‘physical health’ Follow-up at 12 and 24 weeks suggested that the improvements noted in exercise self-efficacy, activity levels and quality of life were maintained and were independent of the exercise programme.	Some concerns about risk of bias (CRoB).Small sample size. The intervention needed to be extended to accurately measure HAP. Weaknesses within the chosen measures.
Huijbregts et al. [34] CanadaMixed methods study	N = 18 (mean age 61.8 (IG) and 65.6 (CG) in yrs). Medical diagnosis of stroke. Completed active rehabilitation. Chronic stage. Living in the community.	IG: Telehealth MOST intervention was implemented using videoconferencing. MOST self-management programme included: Discussion and exercise. Goal-setting andproblem-solving, Exercise, and community- reintegration skills. CG: Waiting list control group. Duration: 18 sessions over 9 weeks. Format: Group therapy. Delivered by: Trained health professional facilitators.	TF: Unclear. SM strategies: EducationProblem solvingGoal settingSocial support.	Berg Balance Scale (BBS), The Reintegration to Normal Living Index, The Stroke-Adapted Sickness Impact Profile, Chedoke-McMaster Stroke Assessment Activity Inventory, Goal Attainment Scaling, and The Geriatric Depression Scale.	There was a significant difference in BBS scores between the T-MOST group and the WLC group (mean difference −4.27, 95%CI: −6.66 to −1.87).	High risk of bias (MMAT). Small sample size No randomisation High risk of selection bias due to recruitment strategy. Baseline differences between groups were not clear.
Kanai et al. [35] JapanPre–post interventional study	N = 22 (mean age 62.5 yrs). Acute ischemic stroke. Able to walk without assistance or gait aid Within seven days of admission.	IG: 40–120 min of a supervised rehabilitation program 5–6 times a week until discharge. Instruction on the self-monitoring approach and discussed physical activity (PA) targets, Exercises included body stretches, weight resistance exercises, aerobic exercise. Accelerometer worn 24 h/day until discharge Duration: 11 days. Format: One-to-one. Delivered by: PT at hospital	TF: Self-efficacy. SM strategies: EducationGoal settingAction planningSelf-monitoring.	The daily number of steps was taken as an index of Physical Activity andSelf-efficacy for physical activity (SEPA) scale.	PA during the intervention was higher than that at the baseline measurement (5709.4 ± 2236.1 vs. 2813.9 ± 1511.9 steps/day, p < 0.001). Self-efficacy for PA during the intervention was also higher than that at the baseline measurement (76.4 ± 18.8 vs. 58.9 ± 29.0 points, p < 0.001).	High risk of bias (CASP). Very small sample size. No control group. Was not statistically powered to detect changes in the outcomes. Used only the number of steps/day as the measure of PA. Did not assess psychological factors or pre-morbidity exercise habits. Did not conduct functional tests at discharge.
Kendall et al. [36] AustraliaRCT	N = 100 (mean age 65.96 yrs). First stroke. Subacute stage. No dementia or psychiatric illness. Sufficient English language. Expectation of discharge to their homes.	IG: SM education programme targetting mobility and exercise. Duration: 7 weeks. Format: Group Delivered by professionals in community settings.	TF: The Chronic Disease Self-Management Course was used to operationalise the concept of psychosocial skill expansion. SM strategies: EducationGoal settingAction planningGroup interaction and Support.	Stroke Specific Quality of Life scale (SSQOL) and the Self-efficacy Scale.	The study identified a significant impact of the intervention on the quality of family roles, self-care, work productivity, and functioning in daily activities within SSQOL (p = 0.05). The control and intervention groups differed significantly in self-efficacy levels across all times, F(1, 93) = 9.45, p = 0.003, including pre-intervention.	Some concerns about risk of bias (CRoB). Minimal data was available about the clinical status of the participants. People with language difficulties were excluded.
Malagoni et al. [37] Italy Feasibility and pilot RCT	N = 12 (mean age 66.5 ± 11.9 yrs). People with chronic stroke. Ability to ambulate independently at least for 10 meters on level ground. FAC > 3. Ability to perform TUG.	IG: Structured home-based exercise programme with 2 10-minute sessions/day (6 days/week) of intermittent walking. CG: Standard supervised group therapyprogramme. Duration: 10 weeks. Format: Group and individualised sessions at home. Delivered by: Physiotherapists.	TF: Unclear. SM strategies: Self-monitoring and feedback.	Functional outcome measures included 6-Minutes Walking Test, Timed Up and Go, Stair Climb tests, and Physical activity domain of the SF-36 questionnaire.	6-minute walk test and physical activity domain of the SF-36 significantly increased in both groups (p = 0.03). Timed Up and Go improved in both groups, significantly for the home-based exercise group (p = 0.03) while stair climb remained stable for both groups.	High risk of bias (CRoB). Small sample size No blinding
Mansfield et al. [38] CanadaQuasi-experimental feasibility-controlled trail	N = 26 (mean age 62.1 (IG) and 67.1 (CG) in yrs). Any type of stroke. Subacute stage.	IG: PROPEL, included group exercise and self-management. Supervised and individualised aerobic training 3 times a week, An inpatient module and an outpatient module. CG: received in- and outpatient rehabilitation Duration: 6 weeks. Format: Group. Delivered: by a PT and a healthcare student in an outpatient rehabilitation setting.	TF: Transtheoretical model + social cognitive theory and self-efficacy. SM strategies: Goal settingAction planningProblem solvingSelf-monitoring	Physical activity level was assessed using an accelerometer, heart rate monitor, and the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), the Short Self-Efficacy for Exercise (SSEE) scale, the Short Outcome Expectation for Exercise (SOEE) scale, and the Barriers to Being Active Quiz (BBAQ).	PROPEL participants had a higher participation in physical activity than COMP participants (Hedge’s g ≥ 0.5),reported higher SSOE scores (Hedge’s g: 0.50) and fewer significant barriers to physical activity in the BBAQ than COMP participants (Hedge’s g: −1.18).	Serious risk of (ROBINS-I). Extremely low recruitment rate. Groups were not comparable at baseline. Patients with communication difficulties were excluded. Only 34% of daily heart rate data were available.
Olney et al. [39] CanadaRCT	N = 72 (mean age 63.5 (IG) and 65.8 (CG) in yrs). Chronic stroke survivors. Able to walk a total of 15 min with rests (with or without assistive devices except a 4-point walker). Able to tolerate activity for 45 min with rests. No severe coronary artery disease.	IG: One week supervised instruction program followed by a 9-week unsupervised home programThe unsupervised group had exercises prescribed to them and written instructions to monitor and progress.. CG: 10-week supervised strengthening and conditioning program (supervised) Duration: 10 weeksFormat: group format for the supervised sessions and 1 to 1 for the unsupervised sessions. Delivered by: therapist at rehabilitation centre for the supervised group and at home for the unsupervised group.	TF: Unclear. SM strategies: Education and Self-monitoring.	Primary Outcome: Walking speed (6MWT). Secondary Outcomes: Human Activity Profile (HAP) adjusted activity score, Medical Outcome Study 36-Item Short-Form survey (SF-36), Physiological Cost Index, and lower extremity muscle strength.	The 6MWT speed increased significantly in both groups and remained significantly improved at one year. The HAP showed an increasing trend only in the supervised group and was significant at one year. The SF-36 Physical component summary score increased significantly in the supervised group and remained improved at one year; the unsupervised group showed significant improvement at one year.	Low risk of bias (CRoB). It was not possible to blind participants and testers. The generalisability of the findings might be limited due to restricted eligibility criteria of participation.
Paul et al. [40] UKQuasi-experimental pilot study	N = 23 (mean age 55.3 (IG) and 56.3 (CG) in yrs). Single unilateral stroke. Discharged from rehabilitation. Chronic stage. Able to walk independently with or without using an aid or orthosis. Able to comprehend instruction.	IG: STARFISH program included a mobile phone app-based intervention, with evidence-based behaviour change techniquesThe intervention started with 1 week of baseline step count using phone accelerometer, followed by use of the STARFISH application over a 6-week period. CG: Usual care. Duration: 6 weeks. Format: Group. Delivered: through a mobile app.	TF: Behaviour Change Techniques (BCTs). SM strategies: Feedback, Self-monitoring and Social support	Physical activity (steps/day), Ten-Meter Walk Test, Sedentary time, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Stroke Specific Quality of Life Scale, and Psychological General Well-Being Index.	The average daily step count increased by 39.3% in the intervention group and reduced by 20.2% in the control group (p = 0.005 for group–time interaction). Similar patterns of data and group–time interaction were seen for walking time (p = 0.002) and fatigue (p = 0.003).	Moderate risk of bias (ROBINS-I). Sample was not inclusive for stroke population. Duration of the intervention was short. Assessor was not blinded. No randomisation. The sample was heterogeneous in PA. Mobile phone accelerometer needs validation.
Portz et al. [41] USAMixed-methods study	N = 13 (mean age 73.23 yrs). Individuals with chronic stroke (> 6 months). Had a fall or current fof. Completion of post-stroke rehabilitation. Able to stand, at risk for falls (≤ 46 on the Berg Balance Scale). Able to understand English. Score of ≥ 4 out of 6 on the short Mini Mental Status Exam.	IG: MYOT a yoga-infused self-management intervention. One hour of group self-management education followed by one hour of yoga (2 times per week). Duration: 8 weeks. Format: Group. Delivered by an OT and a research student	TF: Self-efficacy and Problem solving. SM strategies: EducationGoal settingAction planning/Problem solvingSelf-monitoringGroup discussion and activities.	Quantitative Outcomes: Endurance (6-MWT), Strength (30-Second Chair Stand test), and Gait Speed (10-Meter Walk test). Qualitative outcomes: Participant perceptions of changes in physical fitness and PA were collected	Physical fitness outcome measures including endurance and lower and upper body strength significantly (p < .02) improved. Based on qualitative results, participants expressed positive changes in endurance, strength, gait speed, flexibility, and balance. They also reported improvements in walking ability and duration and expressed a desire to continue yoga and increase levels of exercise.	Some concerns about risk of bias (MMAT). The long-term effect of the programme was not measured. It wasn’t clear why some patients did not notice any change.
Preston et al. [42] AustraliaSingle-group, pre-post intervention study	N = 20 (mean age 68 yrs). Discharged home from an acute stroke unit. Subacute stage. Able to walk 10 m across flat ground without any aids at a speed of ≥ 0.8 m/s. Scored ≥ 24 on the Mini Mental State Examination. Resided within 30 km of the hospital. No moderate to severe receptive aphasia.	Five 60-minute home-based sessionsCarer or family member involved. The sessions included: education, goal setting, barrier identification, self-monitoring, and feedback. Duration: 3 months. Format: One-to-one. Delivered by: Physiotherapist.	TF: Behaviour Change Techniques (BCTs). SM strategies: EducationGoal settingAction planningProblem solving Self-monitoring and feedback.	Primary Outcomes: Duration of moderate physical activity in min/day and counts of physical activity in steps/day. Secondary Outcomes: Self-efficacy, walking ability, participation, and quality of life.	At 3 months, participants completed 27 min/day (95% CI 4–49) more moderate physical activity than at baseline and 16 min/day (95% CI − 10–42) at 6 months. Participants perceived the self-management program to be useful and there were few adverse events (muscle soreness, falls, and hospitalisation).	Some concerns about risk of bias (CASP). No randomisation. No control group. There were challenges around using Sensewear armband to collect PA data.
Richardson et al. [43] CanadaCase report	N = 15 (mean age 65.5 yrs). Chronic stroke survivors. First ischemic stroke. Able to walk at least 2.44 mts. Able to transfer to a chair. Some active movement in the UE during recovery. Cognitive function score of 26 points on the Montreal Cognitive Assessment (MoCA). No receptive aphasia. Can communicate in English.	START: Self-Management and Task-Oriented Approach to Rehabilitation Training. Duration: 10 sessions Format: One-to-one. Delivered by physiotherapist at home.	TF: Self-efficacy. SM strategies: Goal settingAction planningProblem solvingSelf-monitoring.	TUG, Barthel Index, Stroke Impact Scale, Patient Activation Measure, modified version of Patient Satisfaction Questionnaire-18.	Significant changes were observed in the TUG (p < 0.01), the Barthel Index (p < 0.01, and the Stroke Impact Scale (p < 0.001).	High risk of bias (CASP). Very small sample size and not inclusive. High possibility of bias as there was no randomisation or control group.
Scrivener et al. [44] AustraliaPre-post single group study	N = 14 (mean age 57 ± 14.2 yrs). Adults with stroke. Discharged from rehabilitation. Chronic stage. Could walk at > 0.4 m/s with/without an aid.	TASK programme. A video-guided exercise programme. The programme comprised of two phases: in phase one, four weeks of the program was supported by weekly supervised sessions at the rehabilitation centre. In phase two, four weeks of the program was completed at home without direct supervision. Format: One-to-one. Delivered by physiotherapist at home.	TF: Self-efficacy. SM strategies: Education/self-monitoring.	Physical performance, physical activity, and exercise self-efficacy were measured at baseline and 4 and 8 weeks.	Walking speed improved over the duration of the program (mean difference −0.12 m/s, 95% CI −0.22 to −0.02, p = 0:02). Self-efficacy and physical activity did not change over the duration of the program.	High risk of bias (CASP). The sample size for this study was small and diverse in characteristics. High possibility of bias as there was no randomisation or control group.
Sullivan et al. [45] USpre-post test follow up design	N = 11 (mean age 60.4 yrs). Community-dwelling stroke survivors. 21 years old or older. Ambulators. Stroke onset 6 months or more before participation (chronic stage).	A pedometer monitored, community-based intervention was used for 6 weeks. A briefverbal educational module was provided to eachparticipant addressing the benefits of exerciseafter stroke, pedometer use, and completion ofdaily exercise diaries. Duration: 6 weeks. Format: One-to-one. Delivered by: therapist at home through telephone coaching sessions.	TF: Self-efficacy. SM strategies: EducationGoal setting and decision makingSelf-monitoring.	Primary Outcomes: Walking speed (10-mWT) and endurance (6MWT). Secondary Outcomes: the Activities-Specific Balance Confidence Scale, Stroke Impact Scale–16 (SIS-16), and a pedometer satisfaction survey.	There were low effect sizes for changes in SIS-16 (0.312) and 6MWT (0.293). Increasing steps correlated with increased perception of physical function.	Some concerns about risk of bias (CASP). Small sample size. The heterogeneity of participants may have affected results. Possibility of a ceiling effect for the steps/day. Pedometer was inaccurate with participants who walk slower than 0.5 m/s. Short duration of intervention.
Taylor et al. [46] CanadaPre-Post intervention feasibility study	N = 12 (mean age72.7 yrs). Stroke survivors between 3 and 18 months post-stroke Subacute and chronic stages.	Moving On after STroke (MOST): MOST involves sessions with 1 h of discussion followed by 1 h of exercise (cardiovascular, range of motion and strength components). Participants learn about stroke-related issues, but more importantly, learn problem-solving and goal-setting skillsTwo sessions/week. Duration: 9 weeks. Format: Group with patients and carers. Delivered by: Clinicians via videoconference.	TF: Unclear. SM strategies: EducationGoal settingProblem solvingGroups with support.	Walking endurance (6MWT) Short-Term Goals Goal Attainment Scaling,Berg, Berg Balance Scale, Activity-Specific Balance Confidence Scale), Geriatric Depression Scale and Reintegration to normal living), .	Pre–post improvements were seen in goal setting, mood, balance, balance confidence, and walking endurance. Participants reported that the program provided people with stroke as well as caregivers with greater awareness of stroke, increased social support, and improved ability to cope.	Some concerns about risk of bias (CASP). No control group. No randomisation. Insufficient numbers to compare the health outcomes of the telehealth participants to those in the group receiving face-to-face care.
Treger et al. [47] IsraelRCT (single blinded)	N = 56 (mean age 56.6 (IG) and 62.2 (CG) in yrs). Subacute stage . Ability to walk independently (with or without walking aids). FIM score ≥ 60 at mid-hospitalisation evaluation.	IG: Received detailed instructions for 14 exercises and was instructed to walk for at least 30 min daily. Follow up phone calls. CG: Usual care. Duration: 3 months. Format: One-to-one. Delivered by: a physiotherapist.	TF: Unclear. SM strategies: EducationSelf-monitoring/Review follow up.	The 10-metre walk test (10MWT), 6-minute walk test (6MWT), and Timed Up & Go (TUG) were performed twice; once at the end of the inpatient rehabilitation period and three months later.	A significant improvement was shown in the intervention group in 10MWT (p = 0.008), 6MWT (p < 0.001) and TUG (p = 0.009).	Moderate risk of bias (CRoB). Participants were not blinded. Participants received instuctions from therapist without involvement in goal-setting or planning.
Van den berg et al. [48] AustraliaRCT (proof of concept)	N = 63 (mean age 64.5 (IG) and 70.1 (CG) in yrs). Stroke survivors within subacute stage. With mobility problems (FAC score < 5). Caregiver to participate in the programme. Had sufficient cognition to take part and no depression (HADS score < 11).	IG: CARE4STROKE: Caregiver-mediated exercises with e-health support Telerehabilitation services. Participants had 30 min, 5x a week Exercises executed by a caregiver plus usual care. CG: Usual care. Duration: 8 weeks. Format: One-to-one. Delivered by: Physiotherapist and caregiver at rehabilitation centre or nursing home and continued at home if patient discharged before finish.	TF: UnclearSM strategies: Self-monitoringCaregivers’ support.	Primary outcome: The SIS-mobility domain. Secondary outcomes: Length of stay, Motor impairment, Strength, Walking ability, Balance, Extended activities of daily living, Psychosocial functioning, Self-efficacy, QoL, and fatigue. Additionally, caregiver’s self-reported fatigue, symptoms of anxiety, self-efficacy, and strain were assessed.	Intention-to-treat analysis showed no between-group difference in SIS- mobility; Per-protocol analysis, examining those who were discharged home with telerehabilitation showed a trend toward improved mobility (p = 0.06), significantly improved extended ADLs scores at week 8 (−3.6, p = 0.01) and week 12 (3.0, p = 0.03).	Low risk of bias (CRoB). Small sample size. The 2 groups were not comparable at baseline. Study did not provide definitive measures of effectiveness. Participants were not blinded. 11 patients dropped out (high attrition). Study was not designed or powered to detect adverse events.
Vloothuis et al. [49] NetherlandsRCT (proof of concept)	N = 66 (mean age 59.26 (IG) and 60.53 (CG) in yrs). 34 inpatients with stroke. Subacute stage. Lived independently before the stroke. Discharged home. Able to follow instructions (MMSE > 18 points). FAC Score < 5. Had a caregiver to assist.	IG: CARE4STROKE: Caregiver-mediated exercises with e-health support Telerehabilitation services. Participants had 30 min, 5x a week Exercises executed by a caregiver plus usual care. CG: Usual care. Duration: 8 weeks. Format: One-to-one. Delivered by: therapist and caregiver at rehabilitation centre or nursing home and continued at home..	TF: Assumptions that more training is better (Motor control theory). SM strategies: Goal settingCaregivers’ support.	Primary outcomes: SIS-mobility domain . Secondary outcomes: Motor impairment, Strength, Walking ability, Balance, Mobility and Extended ADL of patients, Caregiver strain of caregivers, and Mood, Self-efficacy, Fatigue and QoL of both patients and caregivers. Outcomes were assessed at baseline, 8 and 12 weeks after randomisation.	No significant between-group differences were found regarding SIS-mobility after 8 and 12 weeks.	Low risk of bias (CRoB). Variability in the decision for discharge. Patients were not included at fixed times after stroke. Study may be under powered.
White et al. [50] AustraliaMixed methods study	N = 22 (mean age 65.76 yrs). Community dwelling stroke survivors. Chronic stage. Not accessing other rehabilitation services at the time of enrolment.	MASTERSTROKE A secondary prevention stroke group program with two 2-h sessions weekly (1 h for education and 1 h for exercise). The exercise component incorporated fitness, strength, mobility and balance and education focused on secondary stroke prevention whilst also providing chronic condition self-management support. Duration: 9 weeks. Format: Group.Delivered by: PT and multi-professional community-based team.	TF: Unclear. SM strategies: EducationGroup support.	Timed Up and Go (TUG), Six Minute Walk Test, Participants’ perceptions were qualitatively collected.	TUG (mean change = 3.89, p = 0.00), and quality of life scores (mean = 0.25, p = 0.01). Qualitative responses results confirmed increases in knowledge about stroke and exercise tolerance, successfulness of a group program and lifestyle modification post-stroke.	Some concerns about risk of bias (MMAT). Small sample size. Was not statistically powered, nor controlled. The assessors were also the therapists who implemented the programme. Qualitative interviews were limited to one per person that could limit the ability to capture changes over time and sustainability of modifications.

N: Sample size; SM: Self-management; TF: Theoretical Framework; CRoB: Cochrane's Risk of Bias Tool; ROBINS-I: The Risk Of Bias In Non-Randomised Studies of Interventions; MMAT: The Mixed Methods Appraisal Tool; CASP: The Critical Appraisal Skills Programme; RCT: Randomised Controlled Trial; OT: Occupational Therapist; PT: Physiotherapist; FAC: Functional Ambulation Category; PA: Physical Activity.

Figure 1. PRISMA flow diagram of study selection [53].

Process of removing duplicates and results of screening titles, abstracts, and full texts of eligible studies.

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