Systematic review and meta-analysis of secondary prevention rehabilitation programmes initiated within 90 days of a TIA or ‘minor’ stroke

Conference:

SAPC ASM 2016 - Dublin

Talk Code:

EP2F.09

Presenter:

Neil Heron

Co-authors:

Prof Frank Kee, Dr Christopher Cardwell, Dr Mark A Tully, Dr Michael Donnelly, Prof Margaret E Cupples.

Author institutions:

Dept of GP and Centre for Public Health, Queen's University Belfast

Problem

Often a stroke is preceded by a transient ischaemic attack (TIA) or 'minor' stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate prevention. However, the optimal approach to implement, including non-pharmacological measures at this key time, is not clear. This systematic review appraised available evidence about the effectiveness of rehabilitation programmes initiated within 90 days of a TIA/minor stroke, in terms of reducing modifiable vascular risk factors. Also, the review identified and categorised the specific behaviour change techniques (BCTs) that were employed in the rehabilitation programmes.

Approach

The review focused on adults, males and females, aged 18 years or older, that received a diagnosis of a TIA and/or ‘minor’ stroke, based on clinical diagnosis, or on findings from brain imaging (e.g. CT or MRI head). Any rehabilitation programme or intervention aimed at tackling secondary prevention of vascular events or vascular risk factors following an initial TIA or ‘minor’ stroke were eligible for inclusion, e.g. educational programmes, aerobic or exercise classes, self-management, and lifestyle interventions. The review identified randomised and quasi-randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE(R), Ovid Embase, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Two review authors independently screened titles and abstracts for eligibility and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results.

Findings

Four studies comprising 774 patients across three post-TIA or minor stroke rehabilitation programmes met the inclusion criteria. Two of the four studies had poor methodological quality. The rehabilitation programmes included a post-discharge management model, supervised exercise training programmes and repeated verbal instructions to improve physical activity. The main BCTs were goal setting and instructions about how to perform given behaviours. A meta-analysis did not find any significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls or mortality.

Consequences

The available evidence that post-TIA rehabilitation programmes can address the increased risk of morbidity and mortality in this population is limited. However, effective programmes are likely to include goal setting and repeated verbal instructions. There is a clear need for further robust randomised controlled trials of programmes delivered during the acute post-TIA period that target a reduction in modifiable vascular risk factors and secondary vascular events and that involve a tailored process based on individualised achievement of patient-generated and appropriately scaled and paced goals.

Systematic review registration

PROSPERO reference: CRD42015016450. URL: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015016450

Submitted by:

Neil Heron

Funding acknowledgement:

Dr Neil Heron was funded to undertake this work by a National Institute of Health Research (NIHR) PhD Academic Clinical Fellowship.