Factors affecting community ambulation post-stroke: a mapping review protocol

Participants

This review will consider studies that include community-dwelling individuals at least six months after their first-ever or recurrent stroke, who are at least 18 years of age and do not use a wheelchair as their primary mode of transportation. The use of assistive devices such as canes, walkers, or ankle-foot orthoses is permissible. We will exclude studies that include non-stroke participants or participants living outside their own communities, for example, studies based on inpatient rehabilitation or palliative care. Studies that include participants with and without stroke will be considered for inclusion if data pertaining to stroke survivors can be specifically extracted.

We specifically decided to include only individuals who are at least six months post-stroke as stroke is a life-altering medical condition, not only for the patient but also for their family members.²⁶ During the first six months, patients typically undergo multiple rehabilitative and medical appointments as they adjust to their new normal.²⁷ The factors impacting community ambulation during the acute to subacute stages may not be relevant for the rest of their lives as stroke survivors.²⁸ Six months post-stroke is considered the chronic phase, and from this stage onward, the factors affecting community ambulation may be influenced by multiple physical, personal, and psychosocial aspects, rather than just the acute effects of the stroke.²⁹ Therefore, we chose to map the factors associated with community ambulation only in individuals who are at least six months post-stroke.

Concept

This review will consider studies that explore the concept of post-stroke community ambulation, defined as “independent mobility outside the home, which includes the ability to confidently negotiate uneven terrain, private venues, shopping centers and other public venues”.³⁰ We will include studies that specifically assess community ambulation, that is, walking outside one’s home, through daily stepping activity or self-report questionnaires, or predict community ambulator status based on clinical outcomes such as gait speed or the Six-Minute Walk Test (6 MWT). To ensure that self-report questionnaires focus on assessing true community ambulation, at least 25% of the questions or items on the scale must assess walking activity outside one’s home.²³ Studies will be excluded if they assess general physical activity levels that may not be related to walking outside one’s home such as swimming, yoga, or biking. We will also exclude studies that only assess ‘community ambulation’ through modes of mobility other than walking, such as driving, biking, or using public transportation.

Context

This review will consider studies that quantitatively explore at least one physical (e.g., gait speed, walking endurance, balance), biopsychosocial (e.g., age, gender, race, living with spouse, self-efficacy, depression, use of assistive device), or environmental (e.g., neighborhood walkability, Area Deprivation Index) factor(s) that impact community ambulation post-stroke. Eligible studies will not be limited to any geographic location.

Search strategy

A health sciences librarian (JMD) developed search strategies using research team input and conducted a literature search. The search strategy aimed to locate primary studies published in English. A test search between December 2018 and June 2019 using the CINAHL, PubMed, and PsycINFO databases was performed to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe these articles were used to develop a full search strategy that was peer-reviewed by another health sciences librarian. The following databases were selected for the final literature search because of their topic coverage in the health and social sciences: Applied Social Sciences Index and Abstracts (ProQuest), CINAHL (EBSCOHost), PEDro, Psychology and Behavioral Sciences Collection (EBSCOHost), PsycINFO (EBSCOHost), PubMed, REHABDATA (NARIC), SPORTDiscus (EBSCOHost), and Web of Science (Clarivate Analytics). During the final literature search conducted on July 14, 2023, keywords were truncated and phrase-searched, and the search strategy was translated for each database using controlled vocabulary whenever possible. The search strategy, including all the identified keywords and index terms, was adapted for each information source. The search strategy for PubMed is publicly available as Extended data³¹ (see data availability statement), and all search strategies are available by contacting the lead author. The bibliographies of the articles included in the review will also be screened for additional papers not located in the literature search. Handsearching will not occur, as the selected bibliographic databases will cover all key journals (Clinical Rehabilitation, Journal of Neurologic Physical Therapy, Neurorehabilitation and Neural Repair, Physical Therapy, Physical Therapy Journal, and Topics in Stroke Rehabilitation). The search will be re-run before publishing the full mapping review to ensure that the most recent articles are retrieved.

Articles published on or after January 1, 2001, to the present will be included as the World Health Organization’s International Classification of Functioning, Disability, and Health, was published in 2001. During this time, healthcare professionals transitioned their focus from ‘impairment-based disease’ to ‘function-based health’. The ICF model provides a foundational framework for this mapping review as it focuses on the domains of body structure, body function, and personal factors that could affect activities and participation related to community walking.

Study/Source of evidence selection

Following the updated literature search, all identified records will be collated and uploaded to Endnote Web [Clarivate Analytics^TM, PA, USA] and manually de-deduplicated in preparation for screening in Covidence [Melbourne, Australia]. Following a pilot test, titles and abstracts will be screened by any two out of three independent reviewers (KB, SAC, and DKR) to assess the inclusion criteria for the review. Potentially relevant papers will be retrieved in full, and their citation details will be automatically imported into Covidence [Melbourne, Australia]. The full texts of the selected citations will be assessed in detail against the inclusion criteria by any two of the three independent reviewers (KB, SAC, and DKR). The reasons for excluding full-text papers will be recorded and reported in the mapping review. Any disagreements between the reviewers at each stage of the selection process will be resolved through discussion or by the third reviewer. The results of the search will be reported in full in the final mapping review and will be presented in a PRISMA flow diagram.³²

Data extraction

Data will be extracted from the papers included in the mapping review by two independent reviewers using a data extraction tool developed by the reviewers (see Extended data - Appendix II).³¹ The extracted data will include specific details about participant characteristics, methods of quantifying community ambulation and the corresponding descriptive data, factors assessed and associated with community ambulation, and key findings relevant to the review questions. The draft data extraction tool will be modified and revised, if necessary, during the process of extracting data from each included paper. Modifications will be detailed in the full mapping review. Any disagreements between the reviewers will be resolved through discussion or by the third reviewer. Authors of papers will be contacted to request missing or additional data where required. The included studies will also be critically appraised using a quality assessment tool modified from the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (see Extended Data - Appendix III).³¹ Critical appraisal will also be conducted by the two independent reviewers, and any conflicts will be resolved by the third reviewer.

Data analysis and presentation

Extracted data will be presented in tabular format with a summary of the key findings from each included study. Descriptive statistics and frequency counts will be provided for the participant characteristics and tools used to assess community ambulation. To describe the extent of post-stroke community ambulation, quantifiable data will be pooled from studies that would use a homogeneous assessment tool, such as daily steps, gait speed, or community trips/day. Additionally, based on the extracted data, we will create an evidence map of all examined physical, biopsychosocial, and environmental factors affecting community ambulation post-stroke within the ICF framework. This evidence map will be color-coded to depict the importance of each factor in relation to community ambulation, as determined by the number of studies that analyzed the factors and their cumulative sample sizes. A narrative summary will accompany the tabulated and graphical results and will describe how the results relate to the review’s objectives and questions, followed by recommendations for future research based on the identified gaps in the literature.

Ethical considerations

Ethical approval was not required for this mapping review, as we will use secondary de-identified data.

Dissemination

The results of this mapping review will be disseminated through national and international conference presentations as well as peer-reviewed, high-impact journal publications.

Study status

This study is currently in the data extraction phase and will be followed by data analysis, synthesis, visualization, and drafting of the final manuscript.