Abstract
Background
Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.
Aims/Objectives
The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.
Material and Methods
We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.
Results
Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.
Conclusions
At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.
Significance
Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.
Introduction
The majority of people living with stroke experience persistent challenges with participation in valued activities and social roles [Citation1]. Stroke rehabilitation uses two broad types of interventions to address these challenges, restorative and adaptive [Citation2]. Restorative interventions are designed to remediate stroke-related impairment through normalising body structures and function. Adaptive interventions aim to optimise abilities to carry out important activities through adapting the environment or the approach to the activity. In this way, adaptive approaches promote engagement in valued activities and life roles despite impairment [Citation3].
Current stroke rehabilitation best practice guidelines provide specific recommendations for restorative interventions. For example, to improve upper extremity function named interventions, such as constraint induced movement therapy, are recommended [Citation4]. However, to improve engagement in valued activities and life roles, guidelines provide only general advice [Citation5], such as using collaborative goal setting and providing “targeted, individualized interventions”, without referring to specific named interventions. Clinicians reading such guidelines may be unaware that named adaptative interventions exist.
Numerous adaptive interventions to improve participation following stroke have been developed and evaluated. Two broad approaches appear predominant: metacognitive approaches and self-management approaches [Citation6,Citation7]. For example, Cognitive Orientation to daily Occupational Performance (CO-OP) is a metacognitive approach aimed at promoting improvement in the performance of personally identified, meaningful activities. The Bridges to Self-Management Program is a stroke-specific program based on self-management principles. Each of these interventions has been evaluated in at least one randomised controlled trial [Citation8,Citation9].
While metacognitive and self-management approaches differ with regards to described components and mechanisms of action, they share similar components of goal setting and action planning. Interventions based on a metacognitive approach help patients develop problem-solving strategies to address current and future challenges through learning to think about and analyse the performance problem they are experiencing, propose ways to solve the problem, plan actions to test out their solutions, and reflect on the results of these experiments to further refine performance [Citation10]. Interventions based on a self-management approach assist patients to live well with chronic health issues through developing a better understanding of their condition and its management, and enhancing self-efficacy or confidence in their abilities to find and enact solutions to challenges that arise in living with this chronic health condition [Citation11]. The degree to which current adaptive interventions are informed by each of these approaches, or whether other approaches exist, is not well understood. As well, while the general approach is often identified in the description of an intervention, the theory underlying the development of the intervention may be unclear.
Adaptive interventions are complex in nature [Citation12]. Progress in the science of complex interventions cannot be made without elucidating theoretical principles, hypothesised methods of action, associated treatment elements, and anticipated outcomes [Citation13]. A method of cataloguing adaptive interventions, which allows for comparison of underlying explicit or implicit theory, intervention components, and anticipated outcomes, would be useful. The objective of this scoping review was to develop a framework for adaptive stroke rehabilitation, with an initial focus on interventions guided by a metacognitive or self-management approach, two frequently used approaches [Citation6,Citation7]. The research questions included which named, adaptive interventions have been described and evaluated, what theories are explicitly or implicitly evoked in describing these interventions, what intervention elements are included, what outcomes are anticipated, and how can these interventions be best theoretically grouped.
Material and methods
We carried out a scoping review, following the Joanna Briggs Institute methodology [Citation14]. Details of the review are described in the published protocol [Citation15]. A systematic search for relevant literature from data base inception to 14 April 2020 was carried out in the following: Medline and Medline In-Process (via OVID), Embase Classic and Embase (via OVID), PsycINFO (via OVID), CINAHL (via EBSCOHost), and AARP AgeLine (via EBSCOHost). A supplemental search of OTSeeker and Physiotherapy Evidence Database (PEDro) was also performed.
The search strategy was developed in consultation with a library scientist (LS) to identify rehabilitation interventions to improve participation based on metacognitive or self-management approaches among adults who had experienced stroke. The search strategy was initially developed in Medline (Supplementary Table 1) and then adapted to the other databases. The search included a combination of terms related to the population (e.g. stroke, cerebrovascular accident, adult), concepts (e.g. metacognition, self-management, problem-solving), and the names of known interventions (e.g. Cognitive Orientation to daily Occupational Performance (CO-OP), Bridges Self-Management Program (Bridges SMP).
Eligible studies included those that examined interventions to improve participation globally or specifically. The intervention had to 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 the experience of attempting the activity, emotional support, or education [Citation7,Citation16]. In addition, the study must have included measurement of participation through tools that included specific activities identified by the stroke survivor (specific aspect of participation) or a generic set of activities (broad participation). Measures of participation accepted included broad stroke evaluations that incorporated aspects of body functions and focused evaluations that included one element of participation such as measures of instrumental activities of daily living or leisure. This was done to help us cast a wide net for potential interventions. There was no restriction on research methodology or language. When an intervention was identified during the search, other research articles dealing with that intervention were sought.
Potential studies were excluded if the intervention focused only on the provision of generic stroke education, reduction of a specific impairment such as cognition, or improved adherence to medical management. Studies with samples that included people experiencing non-stroke-related conditions and studies of children (<18 years) with stroke were also excluded.
The library scientist conducted the search in each database and uploaded the results into the web-based management software Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates were removed. Titles and abstracts were screened by two independent reviewers (AC, ME, DK) against the inclusion criteria. Potentially relevant papers were retrieved and assessed against the inclusion and exclusion criteria by two independent reviewers (ME and PD). Disagreements at each stage of the selection process were resolved by discussion between the reviewers and by a third reviewer (PM).
Data were extracted from included papers by two independent reviewers (NG-J and AC) using a data extraction table. A third reviewer (DK or ME) resolved discrepancies between the reviewers. The data extraction table was designed for the collection of data regarding the intervention name, theories identified or implied, and outcomes monitored. For each study, data were extracted from the introduction, intervention description, and discussion that identified or implied the theoretical basis of the intervention. This data included references to theories or theoretical concepts. Theories were considered implied if they were not named but references were made to key theorists. For example, self-efficacy theory was implied if Lorig, who developed a chronic disease self-management approach based on self-efficacy theory [Citation17], was referenced.
Based on the intervention description, information about elements of the intervention were extracted: goal setting preparation, goal setting, strategy development, experimentation, reflection on experimentation, emotional support, and education. Outcomes evaluated were also recorded.
Two authors (ME and DK) examined the interventions for commonalities related to theoretical orientation and mechanisms of action as suggested by the explicit or implied theories, components and outcomes measured. During this examination, they considered different logical groupings and selected the one they felt resulted in the most comprehensive yet succinct grouping. These findings were reviewed by the other authors.
Results
The search resulted in 5278 documents, of which 77 were included following the removal of duplicates and screening (). Twenty-nine different interventions were described in the included studies; eighteen of the interventions were evaluated in at least one randomised controlled trial (RCT) and eight were evaluated in at least two; theoretical foundations were explicitly named in 33 (42.9%) of the 77 studies ().
Figure 1. PRISMA flow diagram.
Table 1. Characteristics of the included studies according to theory groups.
Theoretical orientation (explicit and implicit) and mechanisms of action, as suggested by these theories and the components and outcomes measured, were examined across interventions. Then, several possible logical groupings were proposed and considered. The grouping that best characterised succinct and meaningful relationships between the interventions related to how the intervention was seen to improve participation. This was termed the overarching theoretical driver – that is, the driver that primarily explained the relationship between the intervention and enhanced participation. Three overarching theoretical drivers were identified: learning, motivation, and coping (). The greatest number of named interventions were coping-driven (16 interventions, 44 studies), followed by motivation-driven (8 interventions, 13 studies), and learning-driven (5 interventions, 20 studies) ().
Figure 2. Theoretical drivers and elements.
The theories guiding learning-driven interventions were Learning Theory and Cognitive Learning Theory. Intimately linked, these theories posit that people acquire the ability to do things through a thinking and experiential process (metacognition), that begins with setting a goal, and proceeds through steps of planning a strategy to achieve the goal, experimenting with this strategy, and then evaluating the results [Citation92]. Learning-driven interventions, therefore, would be expected to include elements that focus attention (goal-setting preparation, goal setting), promote thinking through the task such as mental imagery or use of a problem-solving framework, and application or testing of plans and reflection on the results. In study descriptions of learning-driven interventions, at least 75% of the intervention descriptions included goal setting, strategy development, experimentation, and reflection (). One intervention, Activating Physiotherapy, was included within the learning approaches because the authors stated it used metacognition. However, the intervention did not contain any metacognitive elements.
Table 2. Number of studies evaluating the self-management components.
Learning-driven interventions would not necessarily be expected to include education (except for education related to metacognition) or emotional support. Just over half (11 or 55.0%) of the learning approaches included education, while two (10.0%) of the interventions included emotional support ().
Specific participation was assessed in seven of 20 (35.0%) of the learning-driven intervention studies and broad participation was assessed in 8 (40.0%). Cognition and upper extremity function were also frequently tested outcomes (9 studies each, 45.0%). Mobility, depression, and quality of life were included less frequently as potential outcomes (Supplementary Table 2).
The theories guiding motivation-driven interventions included Self-determination Theory, Social Cognitive Theory, and adult learning theories. Self-determination Theory [Citation93] proposes that people will persist in their occupations in the face of challenges when their primary needs for autonomy, relationship, and competence are being met. Interventions leverage motivational forces through working towards valued goals while creating a relationship of trust, supporting autonomy, and encouraging the development of competence. Motivational forces support persistence in problem-solving and experimentation required to improve engagement in valued activities and social roles. Self-determination theory directs therapists to support autonomy (goal setting preparation, goal setting, strategy development, experimentation), competency (strategy development, experimentation, reflection, education) and relatedness (emotional support).
Social Cognitive Theory predicts that people will try to do activities they feel competent to perform. A sense of self-efficacy arises most powerfully from successful experimentation, but also from observation of peers, encouragement, and bodily sensations [Citation94]. Social Cognitive Theory was referred to explicitly or implicitly in both the motivation- and coping-driven interventions. In motivation-driven intervention application of Social Cognitive Theory, improved self-efficacy is a by-product of incremental success; improved self-efficacy supports further persistence in problem-solving through the expectation of success. Social Cognitive Theory directs therapists to include opportunities to experience mastery through practice under conditions that promote success (strategy development, experimentation), support self-evaluation of performance (reflection), allow learning from others’ experience (education), and promote monitoring of physiological states and provide verbal encouragement (emotional support).
Adult learning theories see patients as goal-directed learners interested in practical problems, who may change fundamental assumptions about their values during the learning process [Citation95]. In motivation-driven interventions, adult learning theories direct therapists to harness motivation by focusing on practical problems of high personal interest to the patient. Interventions are designed to ensure the relevance of what is to be learned (goal-setting preparation, goal setting), incorporate previous learning and experiences (strategy development), and promote reflection on experience and how it has led to changed assumptions (reflection).
Motivation-driven interventions would be expected to include elements to ensure activities targeted are of vital interest to the patient while promoting autonomy (goal-setting preparation), supporting competence (strategy development, experimentation, reflection) and developing a relationship of trust (emotional support). In the study descriptions of motivation-driven interventions, goal setting preparation, goal setting and strategy development were included in all intervention descriptions and experimentation was included in all but one. Emotional support was seen mainly in those motivation-focused interventions that named Self-determination Theory as part of their theoretical base. Education was included in all but one of the interventions ().
Specific participation was an outcome in 6 of the 13 motivation-driven intervention studies (46.2%), with broad participation assessed in 8 (61.5%). Cognition was assessed in 4 (30.8%). Upper extremity function was not assessed in any study. Mobility was included as an outcome in 2 studies (15.3%). Depression and quality of life were assessed in 4 studies (30.8%) (Supplementary Table 2).
The theories guiding coping-driven interventions were Social Cognitive Theory and Psychological Stress and Coping Theory. When applied to coping-driving interventions, Social Cognitive Theory proposes an improvement in self-efficacy as the dominant mechanism of action. That is, intervention helps patients strengthen their belief that they can cope with the effects of illness and carry out their valued activities and social roles. This strengthened belief supports persistence in problem-solving and experimentation required to improve engagement in valued activities and social roles [Citation94].
Psychological Stress and Coping theory posit that successful coping with difficult situations entails accurate assessment of threats and the use of active strategies, rather than passive strategies, to mobilise appropriate resources. Interventions informed by Psychological Stress and Coping theory see the mechanism of action as lessening gaps between threats and perceived resources, which leads to decreased stress and more effective coping with problems in day-to-day life [Citation96].
Coping-driven interventions would be expected to include elements that improve self-efficacy (goal setting, strategy-development, experimentation, reflection) and the ability to evaluate and respond to threats presented when trying to participate in valued activities despite impairment (education, emotional support). The majority (53-69%) of coping-driven intervention descriptions included goal setting, strategy development, experimentation, and reflection. Over half of the descriptions included education and approximately one-third included emotional support ().
In the studies of coping-driven interventions, specific participation was an outcome in 2 of the 44 intervention studies (4.5%) with broad participation assessed in 11 (25.0%). Cognition was assessed in 12 (27.2%). Upper extremity function was assessed in 3 studies (6.8%). Mobility was included as an outcome in 9 studies (20.5%). Depression was assessed in 17 (38.6%) studies and quality of life were assessed in 18 (40.9%) (Supplementary Table 2).
Discussion
Adaptive approaches to improving participation in valued activities and social roles following stroke represent pragmatic efforts to help people return to satisfying lives despite persisting impairment. The Canadian Stroke Best Practice Recommendations state that there is Level A evidence that ‘People with stroke who experience difficulty engaging in leisure and other social activities should receive targeted therapeutic interventions and individualised plans for participation based on collaborative goal setting with their health-care team’ [Citation5]. However, no additional recommendations are made; this may lead therapists to incorrectly assume that no specific interventions exist. This scoping work uncovered 29 named interventions for improving engagement in valued activities and social roles; their components and mechanisms can be understood through one of three primary mechanisms: learning, motivation, or coping.
Learning- and motivation-driven interventions frequently shared the features of goal setting, strategy development, experimentation, and reflection. This was not surprising given both included learning theories as part of their theoretical bases. What distinguished learning and motivation-driven interventions was the latter’s inclusion of emotional support. Therapists may provide emotional support as part of learning-driven interventions, seeing this as something any good clinician would do to develop a therapeutic relationship [Citation97]. However, these interventions are based on cognitive motor learning theories, which do not refer to emotional support. The hazard here is that without a way to reason about its importance, such support could be seen as optional.
In educational research, emotional support is seen as influencing student selection of socially important goals. Emotional support also allows students to select ‘approach’ goals (goals that require risk-taking to develop a skill), rather than ‘avoidance’ goals (in which the aim is to avoid risk, thus limiting development of skills) [Citation98]. Future work should make explicit the role of emotional support in learning-driven interventions. If there is debate about its importance, learning-driven interventions should be evaluated with and without explicit inclusion of emotional support to determine whether it is indeed a necessary element. Alternately, researchers could consider the possibility of constructing and testing a combined learning- and motivation-driven approach to ensure adequate consideration of relational aspects of intervention.
Notably, there was significant overlap in terms of elements of all interventions regardless of theoretical driver. What differed were underlying ideas about mechanisms of action and related to these, anticipated outcomes. Goal setting, strategy development and experimentation were included in most coping-driven interventions, which seems reasonable given their focus on competency-building. However, coping-driven interventions focus on building competency to deal with stressors, whereas learning- and motivation-driven interventions focus on building competencies for participating in valued activities and social roles. It is not surprising then that studies of coping-driven interventions were less likely to include measures of specific participation. Further examination of coping-driven intervention protocols suggests that goal setting, strategy development, and experimentation regarding valued activities and social roles were minor components of the interventions. This is not surprising as the focus of these interventions was on decreasing stress and improving health management. Given this focus, coping-driven interventions may be less effective for promoting participation without additional sessions focused on patients’ specific valued activity goals [Citation99]. Oh and colleagues provide preliminary evidence of this assertion in their meta-analysis of self-management interventions with action components [Citation99].
Given its attention to the theory underlying intervention, this framework has both clinical and research relevance. While helping clinicians identify specific tested approaches to stroke rehabilitation, it can also help them consider the underlying theoretical approaches and what needs to be included in an intervention to ensure the appropriate use of theory. For example, the underlying theory of all interventions directs therapists to include goal setting, experimentation, and reflection. Finally, this framework can help ensure that team members providing the interventions have the necessary skills in the underlying components. For example, all of the interventions require expertise in helping people develop goals, a skill that is challenging for many rehabilitation providers [Citation100].
Substantial progress in the development of adaptive approaches will best occur when techniques are consistent with the underlying theory and reflect relevant changes as these theories advance. Researchers could use this framework to refine existing interventions, through modifications that create better theoretical consistency and incorporate new developments in the underlying theories. Notably, this framework could be used to better group interventions in systematic reviews and meta-analyses. Meta-analyses that group interventions by theoretical drivers may be helpful in identifying which specific types of interventions (learning-, motivation-, or coping-driven) best address participation outcomes. It appears that current reviews contain all three types of interventions. For example, when we examined three systematic reviews on self-management interventions [Citation99,Citation101,Citation102], we found the inclusion of interventions that could be better classified as learning- [Citation29] or motivation- [Citation41,Citation42,Citation44] driven rather than coping-driven.
There are three main limitations of this review. First, we may have missed participation-focused interventions during our literature search given our initial search focus on meta-cognitive and self-management approaches. There may be other named interventions with different theoretical drivers. Second, we note that the theoretical bases for interventions were explicitly stated less than half of the time. While we were careful in our identification of implicit theory, we may have made incorrect assumptions during this process. Finally, our results are based on the literature to mid-April 2020. While this is a limitation, we note that we were not attempting to calculate the current best estimates of the effects of these interventions. Rather, we were attempting to describe the theoretical orientations of these interventions. A recent search for randomised controlled trials of participation-focused interventions for people who have experienced stroke produced four additional studies. The interventions tested included self-management programs (coping-driven) [Citation103,Citation104] and CO-OP (learning-driven) [Citation105,Citation106], suggesting that our framework is applicable to more recent studies as well.
Despite these limitations, this study makes an important contribution to the literature. An excellent understanding of underlying mechanisms of action is critical in developing, evaluating, and refining complex interventions. Adaptive interventions are frequently delivered by inter-professional teams, increasing the need to be explicit and clear regarding theoretical underpinnings. Increasingly, investigators are mapping out the elements and theoretical connections of participation-directed interventions [Citation107]. By focusing on the underlying theoretical bases, the framework developed in this study provides an important starting point for a broad discussion of elements and mechanisms of action of interventions to improve participation in valued activities and social roles.
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References
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