The use of self-management strategies for stroke rehabilitation: a scoping review

ABSTRACT Introduction Self-management is generally considered a dynamic and collaborative process by individuals and caregivers to manage a chronic condition. Self-management has recently emerged as a promising strategy for stroke rehabilitation. This scoping review aims to examine and summarize self-management strategies utilized by stroke survivors for stroke rehabilitation. Methods PubMed, Scopus, CINAHL (EBSCO), Embase, and ProQuest were searched for articles published between January 2010 and December 2021. Studies were selected if they were published in English in a peer-reviewed journal, utilized a non-experimental research design, and focused on adult stroke survivors. All relevant information from the included articles was extracted in a systematic way using a pre-developed data extraction form. Two authors performed data extraction and quality evaluation independently. All issues were resolved through discussion among the authors. Results We narratively summarized the findings of 15 quantitative, qualitative, and mixed-method studies, including a total of 1,494 stroke survivors. The stroke survivors used a range of self-management strategies for their stroke rehabilitation, including domains related to lifestyle, social support, communication, knowledge and information, and goal-setting. Gender, age, stroke-related disability, fatigue, self-management education, social support, and communication with others were found to be associated with self-management use in stroke rehabilitation. Conclusions This scoping review provides an important overview on stroke survivors’ use of self-management strategies and their experience. Their use of self-management strategies is complicated and multifaceted, comprising several domains and involving a diverse range of approaches and personal experiences. However, we identified several gaps in the literature and more research is required.


Introduction
In 2019, there were more than 101 million stroke survivors worldwide, with 12.2 million new cases and 6.55 million new deaths. 1 The absolute number of stroke incidence continues to rise for several reasons, including increased average life expectancy, population growth in the majority of countries, and the increased prevalence of potential risk factors for stroke such as obesity, unhealthy diet, and low physical activity. [1][2][3][4] This increase of stroke survivors places a significant burden on healthcare systems. [1][2][3][4] Although stroke is a sudden-onset acute cerebrovascular event, there are numerous longterm physical and mental complications associated with this life-changing event, such as impaired movement, 5 fatigue, 5,6 poor concentration, 5 falls, 5 loss of function of upper limb, 7 problems with swallowing, 7 aphasia, 8 seizure, 9 anxiety, [10][11][12] confusion, 11 and depression. [10][11][12] Many stroke survivors require help for basic daily tasks. [13][14][15][16][17] Stroke rehabilitation is a dynamic, progressive, goal-directed process that attempts to maximize stroke survivors' functional capacities, symptom management, cognitive skills, daily activities, communication interactions, and social involvement, as well as to avoid subsequent strokes. 13,[18][19][20][21][22] Selfmanagement, which is generally considered a dynamic and collaborative process by individuals and caregivers to manage a chronic condition, is an approach to addressing stroke survivors' long-term needs in stroke rehabilitation. [23][24][25][26] Since the mid-2000s, self-management strategies have gained increased attention among stroke survivors, family members/carers, and healthcare professionals as a means of addressing long-term unmet needs of people in post-stroke life. 2,15,[26][27][28][29][30][31][32] According to several international stroke guidelines, all stroke survivors should undertake self-management strategies for their stroke rehabilitation. 22,[33][34][35][36][37] There is limited documentation on the use of self-management strategies among stroke survivors, and research on this topic is relatively new. 2,26,28,30,38 Previous reviews, mainly based on randomized controlled trials, showed that selfmanagement interventions such as exercise/ physical activity, a nutritious diet, self-management educational training, and social support were effective in stroke rehabilitation. 2,22,30,[33][34][35][36][37][39][40][41][42][43] Considering the growing burden on stroke survivors and the wider society, research is required to explore not only the efficacy of particular selfmanagement interventions, but also the types of self-management strategies used by stroke survivors and the experiences/perceptions of those stroke survivors around such use. To address this gap, this scoping review aims to examine and summarize the self-management strategies used by survivors after stroke and stroke survivors' experiences of using the self-management strategies.

Design
The protocol of this review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) (number: CRD42021222131). This scoping review was undertaken following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses -Extension for Scoping Reviews) guidelines (Appendix 1). 44

Search strategies
We systematically searched peer-reviewed journal articles published between January 2010 and December 2021 on the use of self-management strategies among stroke survivors. The databases including PubMed, Scopus, CINAHL (EBSCO), Embase, and ProQuest were searched for literature. A similar search strategy was used to search these databases via the following keywords and/or MeSH words 'stroke,' 'stroke rehabilitation,' 'thromboembolism,' 'brain hemorrhages,' 'brain ischemia,' 'ischemic attack,' 'tia,' as well as terms regarding self-management including 'self-care,' 'selfmanagement,' 'self-directed,' 'self-efficacy,' 'selfadministered,' and 'self-monitored. ' The searches were restricted to articles published in the English language. Additionally, to guarantee that all relevant literature was included, a manual search of Google Scholar was undertaken using the above keywords.

Selection criteria
The identified articles obtained from the search of each database were imported into EndNote X7. Duplicate items were identified and removed from the results. All observational studies that reported on the use of self-management strategies among adults living with stroke were considered for inclusion. There were no restrictions on the forms of self-management, nor their frequency or duration. However, this review excluded other literature reviews and articles reporting animal studies, clinical trials, conference abstracts, editorials, commentaries, letters to the editor, and case reports.
Two authors (M.S.R. & W.P.) independently retrieved the titles and abstracts to identify the articles that met the inclusion criteria, then critically examined by another author (D.S.). When the title and abstract did not provide enough information, the whole text was examined. Two authors (M. S.R. & W.P.) examined the full texts of potentially eligible articles before final inclusion. In cases of disagreement to include/exclude articles, the other authors (D.S. and J.A.) were consulted. Figure 1 depicts the study selection process via the PRISMA flowchart. A total of 10,087 items were retrieved via the five electronic databases, and further 35 items were identified during the manual search. After removing duplicates, 7,744 items were screened for titles and abstracts, and 7,670 publications were removed as they were considered irrelevant to the review. The remaining 74 items were assessed on the basis of their full texts, where 59 items were excluded for specific reasons. The common reasons for exclusion were: not the outcomes of interest, different target population, and not the appropriate research design. Finally, 15 articles from 15 unique studies met inclusion criteria and were included in this literature review. [11][12][13]19,

Quality appraisal
Using the Modified Newcastle-Ottawa Quality Assessment Scale, we evaluated the quality of the quantitative observational studies (i.e. crosssectional questionnaire surveys). 56 The maximum score for this scale is 10 (1 star = 1 point) while the minimum score is 0, and studies having a quality score of 6 or above are considered to be of high quality. 57 In addition, the quality of the included qualitative studies was appraised using the Critical Appraisal Skills Programme (CASP) qualitative checklist. 58 The CASP is the most widely used technique for assessing qualitative research, with a grading system ranging from 0 to 10 based on 10 methodological questions. 59,60 While no scoring rubric has been indicated in the CASP checklist, the following score can be given to each question: 'Yes' (1), 'Can't tell' (0.5), and 'No' (0). 61 Studies with a quality score of 9-10, 7.5-8.9, or less than 7.5 based on the CASP checklist criteria are categorized as high-quality, moderate-quality, and lowquality, respectively. 61   P.) independently conducted the quality assessments and assigned ratings to each study; any differences in the scores were resolved by discussion among all authors.

Data extraction and synthesis
All relevant data of the included articles were extracted in a systematic way using a predeveloped data extraction form that presents the general characteristics of included studies, such as the year of publication, country of the study, inclusion and exclusion criteria of participants, study design, outcome measures, stroke survivors' characteristics, self-management strategies for stroke rehabilitation, perceptions and experiences of selfmanagement strategies. Two authors (M.S.R. & W. P.) independently completed the extraction form and disagreements about the extracted data were resolved by authors' discussion.

Quality appraisal of the included studies
All included studies in this literature review were found to be of high quality (Table 2 and Table 3). The average score for overall methodological quality for the quantitative studies was 6.83 out of 10 (range: [7][8] and that for the qualitative studies was 8.78 out of 10 (range: 8-10). The average score for overall methodological quality for the qualitative part of the mixed method studies was 9.62 out of 10 (range: 9.5-10). Two mixed-method studies 27,52 focused on the qualitative analysis and assessment of their quantitative methodological quality was not possible. The average score for overall methodological quality for the quantitative part of the other two mixed method studies 46,51 was 6 out of 10.

Definition of self-management in stroke survivors
Five articles reported the concept of selfmanagement from the viewpoint of stroke survivors. [15][16][17]27,50 The word "self-management" was unfamiliar to many stroke survivors, but they understood the concept with further explanation and could provide their own definition. [15][16][17] The most common definition about self-management among stroke survivors was the process of maintaining "independence and autonomy," such as doing daily activities independently and seeking support only when really needed. [15][16][17]27,50 The other concepts related to self-management included managing post-stroke life (e.g. engaging in social activities), [15][16][17]27 adopting effective approaches (e.g. healthy lifestyle behaviors) for stroke rehabilitation, 5,18,50 developing a positive attitude to stroke recovery (e.g. setting goals), 15,27 and participating actively in rehabilitation activities. [15][16][17] Common self-management strategies used post-stroke Stroke survivors reported a variety of selfmanagement strategies for stroke rehabilitation Table 4. [15][16][17]27,[46][47][48][49][50][51][52][53]55 The majority of stroke survivors described self-management strategies as essential to and beneficial for their stroke rehabilitation, especially for maintaining daily activities and the improvement in emotions such as excitement, pride, Any disorders that may impair an individual's ability to provide consent.

Social support-led self-management strategies
Receiving social support was an important selfmanagement strategy for stroke rehabilitation, including support from family members/friends, peers, and clinicians. [15][16][17]27,[49][50][51][52][53] Family support was perceived as essential for managing stroke survivors' functional limitations, particularly during the early stages post-stroke. [15][16][17]49,50 However, some stroke survivors reported that increased family assistance could impede their selfmanagement development. [15][16][17]50 In addition, some stroke survivors indicated the support from health professionals could assist them in identifying effective and appropriate self-management activities. 15,17 Moreover, three qualitative studies reported that peer support is beneficial in the improvement of mental well-being, confidence, and self-management knowledge. 16,17,53 Communication related self-management strategies The involvement in communicative activities with family/friends, carers, health professionals, and other peers was also perceived as a necessary and Main components of self-management Self-management strategies Lifestyle-related selfmanagement [15][16][17]27,[46][47][48][49][50][51][52][53]55 1. Maintaining independence (e.g. doing things for yourself, looking after yourself, try to manage everything individually) 2. Engaging in physical activities/ exercises for rehabilitation 3. Carrying out normal tasks and responsibilities as much as possible (e.g. dressing and grooming, eating a meal with knife and fork, cooking a family meal) 4. Cope with the stroke related consequences (e.g. fatigue, pain, frustration) 5. Changing lifestyle behaviors (e.g. smoking cessation, modifying diet, sufficient sleep, maintain personal hygiene, appropriate exercise, being proactive). 6. Doing enjoyable activities (e.g. singing choir, walking the dog) 8. Ongoing monitoring (e.g. the quality of the speech) 8. Using strategies to maximize the quality of speech (e.g. speak slowly, shout louder, focused on listener, breath support, reducing external distraction, word substitution) 9. Increasing mobility 10. Involving the affected arm in every possible activity 11. Creating the environment at home for conducting rehabilitation (i.e. embedding rehabilitation into everyday life) 12. Using self-care products (e.g. multivitamins/minerals, vitamins, fish oil/omega 3, hypericum, CoQ10, herbal medicines, homeopathic remedies, folic acid, garlic and ginkgo) 13. Using necessary devices (e.g. electric stimulation devices, braces, and splints) 14. Using strategies to manage psychological and emotional effects of stroke like stress or anxiety reduce anxiety (e.g. uses of self-help relaxation, mindfulness and spiritual self-care techniques) 15. Using strategies to manage memory problem and loss of concentration (e.g. writing a note) Social support-led selfmanagement 15 1. Participating in self-management educational programs 2. Learn from experiment and error in everyday life as well as from shared experiences of other stroke survivors 3.Seeking appropriate information about stroke rehabilitation 4. Expanding professional driven rehabilitation activities (e.g. through modifying, adapting, adding new meaningful self-management strategies, and shared strategies of other stroke survivors) 6. Identifying the limitations and strength (e.g. energy level) 7. Identifying the most helpful professionals for specific issue 8. Discovering new strategies to self-manage (e.g. recording the speech to identify problematic words and then practice the problematic words) 12. Identifying needs, local support, and stroke related services 14. Identifying important self-management strategies that help to improve Goal-setting related selfmanagement 17,27,49-51,53 1. Setting realistic and achievable goals (e.g. mobilizing independently, achieving an ability to resume everyday activities prior to stroke, losing weight, cessation of smoking, maximize the quality of speech, and improving brain and memory function) 2. Action plan Table 5. Stroke survivors' views and experience of self-management strategies.

Study
Stroke survivors' use of self-management strategies Brady et al 49 1. Various strategies (e.g. breath support and the development of an action plan) were used, aiming to improve the speech production and communicative interactions. 2. Almost all participants engaged in speech rehabilitation activities regularly. 3. Most perceived their responsibility, motivation, self-confidence, self-discovery, and determination enabled them to continue selfmanagement activities. 4. Family members, friends, and healthcare professionals played a crucial role in improving their stroke recovery. 5. Some perceived implementing professional-directed strategies were beneficial for stroke management. Hirsche et al 53 1. The respondents participated in the chronic disease self-management (CDSM) programme.
2. Goal-setting, coping with the situations and action planning were identified as the most important self-management strategies to improve. 3. Several participants reported that their lifestyle behaviors had improved (e.g. smoking cessation, modifying diet, improving exercise habits) through participation in the CDSM program. 4. Several stroke survivors acknowledged that peer support benefitted them considerably in gaining knowledge. Peer support enhanced their mental well-being, confidence, communication ability, and social participation. Boger et al 17 1. The word 'self-management' was unfamiliar to the participants; but they understood the concept after additional explanation. 2. While the majority of participants believed that self-management was a helpful strategy, not everyone agreed.
3. In the face of functional limitations caused by a stroke, the majority of participants indicated that receiving or asking support from family, friends, formal/informal carers, and health professionals was essential for self-management and stroke rehabilitation. 4. Some stroke patients thought that enhancing their communication skills would assist them in self-management activities. 5. Self-confidence, professionals support, peer-support, determination, appropriate decision-making, and supportive environment helped some participants in developing self-management skills. 6. Stroke survivors gained self-confidence and psychological satisfaction in peers who appeared to be dealing with more challenging conditions, although peer comparison did not always result in an increase in confidence. 7. The availability of peer support inspired individuals to experiment with various self-management techniques, and it also allowed participants to make health care and self-management decisions. 8. According to the participants, stroke clubs were an excellent source of peer support. They claimed that being in a group setting with their peers contributed in the development of their self-management skills. 9. While some stroke patients struggled to continue exercising without assistance of others, some patients remained committed despite obstacles. 10. Many respondents believed that without sufficient information, appropriate decision making was impossible. They perceived that seeking relevant information was a key part of the overall self-management. 11. Stroke patients reported getting a great deal of information regarding self-management during their inpatient rehabilitation, but the information was not useful after discharge as they were not prepared to accept it in the early period of stroke. 12. Many participants expressed a lack of professional support (e.g. insufficient emotional support, lack of qualified specialists). Satink et al 16 1. Although most participants were unfamiliar with the word 'self-management,' they understood the concept of it without further explanation. 2. Participants demonstrated self-management as a multidimensional, long-term, individual learning process. 3. Accepting the stroke consequences and current situation was recognized as important for self-management. 4. Some respondents commented that engaging in enjoyable activities (e.g. choir singing, dog walking) led them to feel that they could also maintain their daily lives. 5. Participants perceived that their ability to identify limitations and strengths (e.g. energy level) facilitated their adjustment capability and post-stroke life management. 6. Many participants stated that family support was essential during their rehabilitation process and that without it, they might not have been able to maintain self-management strategies and return to their normal routines and activities. 7. Some participants indicated that while family support can help in self-management, taking on so many tasks prevent stroke survivors from practicing and improving self-management skills. 8. Some stroke patients emphasized the importance of peer support in self-management process as the fellow sufferers truly understood one another and did not hesitate to seek assistance. 9. Several participants expressed concern about the insufficiency of professional care following discharge. Another concern expressed by some patients was a lack of emotional support from healthcare professionals. 10. Some stroke survivors recommended that having a coach visit their home on a regular basis would let them learn about increasing their ability to manage their strokes through the development of self-management skills. Kidd et al 27 1.The participants engaged in nurse-led 4-week 'tailored self-management action plan' program for their stroke rehabilitation. 2. Most of the respondents (85%) actively engaged in self-management activities and they were also able to self-manage during illness, stress, and/or anxiety. 3. Stroke patients (n = 3, 15%) who did not participate actively in nurse-led rehabilitation activities had lack of knowledge to self-manage, lack of confidence, fatigue and moderate/severe disability 4. Participants, with the assistance of their nurses, set a variety of goals (e.g. self-mobility, weight reduction, quitting smoking, returning to a normal life, improving memory function, and fulfilling social duties) and goal-setting was described as a beneficial strategy for stroke rehabilitation. 5. Nearly all stroke patients (25/26) acknowledged that they received appropriate, practical, and timely self-management guidance and advice during the program, and this program increased their knowledge, confidence, and skills to manage their post-stroke life.
(Continued)  1. Over time, the concept of self-management had changed from managing daily activities to taking on a full role to maintaining a meaningful and valuable life after a stroke. 2. Participants developed self-management skills gradually through participation in daily activities, which enabled them to manage disabilities and personal roles. 3. During the participants' everyday activities, several self-management processes were simultaneously happening, including interacting with other people, seeking support, learning from their experiences, and coping with their own difficulties. 4. Participants considered keeping a positive outlook was an important self-management strategy. 5. Receiving support was considered as a crucial component of self-management by majority of the participants. Developing comanagement with partner was also perceived as beneficial to self-manage. 6. Few participants felt that increased family assistance could impede their ability to develop self-management skills. 7. According to some participants, identifying limitations and learning to handle them was a part of self-management process. Some understood their inability to perform certain tasks due to their stroke, and avoiding them was regarded as a part of the self-management techniques. 8. Several stroke survivors experienced invisible problems such as concentration loss or hypersensitivity and they learned to manage them through trial and error of everyday life (e.g. using shopping list). 9. Several expressed that enhancing their communication skills (specially to obtain information and get support) was an important selfmanagement technique. 10. Many stroke survivors narrated that action plan helped them to perform activities. 11. Increased mobility enabled participants to expand their social circles and took control of when and where they went. It was connected with their physical recovery, resource utilization, and transportation arrangements. 12. During their final visit, the authors found that most participants had achieved the ability to maintain themselves and their everyday lives through active participation in daily activities. 13. Although most of the participants gradually learnt to self-manage their daily activities, there were some situations where some were unable to manage their own lives. Sadler et al 15 1. Over half of participants emphasized the important role of maintaining a good relationship and communication with therapists, mentioning it as a significant component of early recovery. 2. Several stroke survivors stated that their good relationships with therapists enabled them in acquiring the necessary knowledge and expertise. 3. More than half of stroke survivors reported that they relied on family members for both practical and emotional support after their stroke. Guan et al 54 1. The mean self-management behavior score was 151.95 ± 23.58 out of a maximum 250. 2. Education level, social support level, stroke knowledge level were significantly associated with stroke patients' self-management behaviors in recovery. Kulnik et al 52 1. The patient followed professional advice to manage their affected arm, particularly in the first few weeks and months following the stroke. 2. Participants emphasized that arm rehabilitation is a challenging and long-term process (may be years), and that there are no shortcuts to recovery. 3. According to the participants, maintaining a positive outlook and hope enabled them to continue with rehabilitation activities and manage their severely impaired arm. 4. Several stroke patients said that rehabilitation professionals projected their arm would never recover, which had a profound negative effect on them, and they advised that health personnel should refrain from making such detrimental statements. 5. Self-management skills were expanded through modifying, self-discovery, adding new meaningful self-management strategies. 6. Stroke survivors expressed anger, frustration, concern, and grief on losing an arm or failing to improve, but demonstrated positive feelings such as enthusiasm, pleasure, pride, and self-confidence upon making progress. Nott et al 51 1. The stroke patients engaged in a 12-week self-management program led by occupational therapists. The program included a number of activities, such as assisting participants in setting realistic and achievable goals (e.g. self-care, resuming daily activities, community engagement) and learning strategies for accomplishing them. 2. According to several patients, occupational therapy coaching provided them with current information, increased their sense of selfefficacy, and improved their skills. 3. Participants who experienced both in-patient rehabilitation and self-management programs at home acknowledged the advantages of rehabilitation at home. They stated that their home setting offered them with more opportunity to participate in recovery activities and work toward their goals than in-patient rehabilitation. 4. The perceived self-efficacy by stroke survivors was found to be a key mediator of improvements in occupational performance and work satisfaction. 5. Self-efficacy was found to increase with family, friend, and community support and decrease in the lack of support. 6. The support received during the program helped stroke survivors to "get back to normal" 7. Health professionals often used timetable to accomplish goals, which benefited some individuals but it did not useful to everyone. 8.Other stroke survivors' shared experiences (e.g. how they are progressing with self-management) motivated them to engage in selfmanagement activities and boosted their sense of self-efficacy. 9. Participants found encouragement and psychological satisfaction in peers who appeared to be dealing with similar or more challenging conditions. Mahmood et al 45 1. Almost 90% of the patients and 92% of the caregivers demonstrated a willingness to engage in mobile-based self-management approaches. 2. Around 72% patients and 82.7% caregivers consented to pay a nominal fee for these kinds of services. 3. Over 80% of the patients and caregivers agreed that a mobile-based home exercise program could benefit stroke rehabilitation, increase stroke awareness, reduce the time and cost associated with utilizing stroke care services, improve follow-up access, and make it easier to obtain necessary information. Wang et al 46 1. Thinking of a pleasant place, breathing watch, positive thoughts, and body relaxation were the most preferred self-help mindfulness and relaxation techniques. 2. Participants mentioned that practicing self-help mindfulness and relaxation techniques assisted them in calming down, relaxing their body (e.g. falling asleep more quickly), and turning their attention away from feelings of fear and worry. 3. Some reported that the techniques helped them preparing for specific stressful activities, such as communicating with other people.

Knowledge and information related self-management strategies
Seven studies reported different self-management strategies in the knowledge and information domain. 16,17,27,[49][50][51][52] Stroke survivors always recognized their needs and then sought relevant information during the stroke rehabilitation. 16,17,49,50 Stroke survivors from three studies 27,51,53 had participated in self-management programs to obtain stroke-related knowledge/information. Those stroke survivors in the programs found that the knowledge and information related selfmanagement strategies could help improve their lifestyle behaviors, social connections, confidence, and the ability to manage post-stroke life. 27,51,53 It is worth noting that several stroke survivors reported the self-management information learned during their inpatient rehabilitation cannot meet their needs once they have returned home. 16,17

Goals-setting related self-management strategies
Setting realistic and achievable goals (e.g. mobilizing independently, losing weight, and fulfilling social duties) was a vital part of self-management strategy for stroke rehabilitation. 27,51,53 Several stroke survivors indicated that their responsibility, motivation, and self-confidence enabled them to continue with self-management activities, and highlighted the important role of sufficient information for setting an appropriate goal. 17,27,53 One qualitative study demonstrates that goal setting can help stroke survivors to develop a routine for monitoring their health condition and improving health behaviors. 53 In addition, health practitioners were reported to play an essential role in assisting stroke survivors in establishing and achieving reasonable goals. 27

Characteristics of stroke survivors who used self-management strategies
One study 53 did not report the gender of the respondents; in the remaining 1481 stroke survivors, 625 (42.2%) were female. Another study 27 did not report the age of the stroke survivors who participated in their evaluation phase, while the rest of the studies did, however, the modes are different. In terms of the stroke survivors' conditions, Brady   Most of the participants reported that spiritual self-care facilitated them in reducing psychological problems associated with stroke, developing a positive outlook, coping with stroke consequences, making appropriate decisions, fulfilling their personal role, increasing their social inclusion, and practicing better self-care. 3. Participants found encouragement and psychological satisfaction in people/peers who appeared to be dealing with more challenging conditions. Sibbritt et al 48 1. Approximately 35.5% and 18.6% participants, respectively, used at least one self-care product and practice (e.g. physical activities/ exercises, meditation, mindfulness, yoga, tai-chi), with vitamin D supplements (15.3%) and omega (14.6%) being the most frequently used self-care products and physical activities/exercises (14.6%) being the most frequently used self-care practice for stroke rehabilitation. 2. Females and younger people were more likely to utilize self-care products and practices. 3. Individuals with slight or moderate disabilities, and those reported high levels of fatigue were more likely to use self-care products. Kuo et al 55 1. The average score for self-management was 110.5 ± 15.12 out of a maximum 150. 2. Higher levels of education, exercising one to two times per week as compared to never exercising, having a stroke within two to six months as compared to 0-1 month, and continuity of care were factors influencing the overall self-management of newly diagnosed stroke survivors.
NR: not reported.
employed stroke survivors with different conditions (Table 1). A study conducted in Australia found that female patients, younger people, individuals with slight or moderate disabilities, and those who reported high fatigue levels (measured using MFIS-5) were more likely to utilize selfmanagement. 48 Another quantitative study among Chinese population found that the education level, social support level, and stroke knowledge level were significantly associated with stroke survivors' self-management behaviors during their recovery stages. 54 Moreover, a quantitative study conducted in Taiwan revealed that higher levels of education, exercising one to two times per week as compared to never exercising, having a stroke within two to six months as compared to 0-1 month, and continuity of care were factors influencing the overall self-management of newly diagnosed stroke survivors Table 5. 55

Discussion
This article provides the first literature that focused on the use of self-management strategies for stroke rehabilitation and stroke survivors' experience in using those self-management strategies. Although self-management approaches have been strongly recommended by several clinical guidelines for stroke rehabilitation, 22,33-37 we only found 15 nonexperimental empirical studies published between 2010 and 2021 on this issue. Most of the included studies were conducted in the high-income countries. Therefore, more studies focusing on the selfmanagement strategies for stroke survivors are required in low-and middle-income countries. Although the studies included in this review were all evaluated as being of a high quality, only one article in this review contains sample size over 500, 48 more studies examining large and/or nationally representative samples are thus required. Also, most included studies were cross-sectional with a short period. Large-scale longitudinal studies are needed to examine the effect of self-management strategies used throughout different stages of the stroke survivors' life and treatment journey.
According to some clinical guidelines, 22,33-37 successful self-management strategies after stroke require an integrated approach that includes an active participation of stroke survivor, family member/carer, and healthcare professions, as well as strong collaboration among them. Our review found that stroke survivors used a range of selfmanagement strategies for their stroke management and rehabilitation, including lifestyle, social support, communication, knowledge and information, and goal-setting strategies. Interestingly, all those five self-management domains identified in this review are currently recommended by clinical guidelines for stroke rehabilitation. [33][34][35][36] In this review, most stroke survivors were found to use different self-management domains simultaneously, and within each of these domains, stroke survivors used a diverse range of strategies for stroke rehabilitation.
Notably, most of the stroke survivors included in this review reported self-management strategies as effective for improving their functional recovery, communication abilities, stroke management, daily living activities, social participation, and mental well-being, as well as for reducing symptom severity. However, it is important to note that these measures of effectiveness are self-reported. Besides, the demographic and healthcare characteristics of those stroke survivors remain unclear. There is a need for further studies in the field of stroke rehabilitation to identify the profile of stroke survivors who use self-management strategies. Moreover, only one study reported the prevalence of the used self-management strategies for stroke rehabilitation and found stroke survivors with higher fatigue were more likely to use self-care products (rather than self-care practices). 48 However, the authors did not examine the association between fatigue level and each self-care product included in the study. In fact, systematic reviews/Cochrane review also indicated insufficient evidence in the effectiveness of self-management interventions for the treatment of post-stroke fatigue, including fatigue self-management led by allied health practitioners. 6,62,63 Further studies thus are warranted to determine the prevalence of use of those common self-management strategies among stroke survivors and their associations with post-stroke fatigue. . This scoping review found that goal setting is utilized as a self-management strategy by stroke survivors of all ages and comorbid conditions. 27,53 Goal setting has been described as a critical strategy for overall stroke rehabilitation and outcome. 2,64,65 It is worth noting that some clinical guidelines strongly recommended that goals should be developed in coordination with the stroke survivor, health professionals, and their family/caregivers, and the goals should be clear, challenging but achievable, and regularly monitored and updated. 33,34,36 Stroke survivors of two studies included in this review reported that goal setting helped them in changing health-related behaviors, and engaging in self-management activities. 27,53 Therefore, future studies should be designed to explore the effectiveness of the common goals set for stroke survivors over time.

Limitations of the study
This scoping review has several limitations. We only included studies written in the English language. Future study that includes articles conducted in languages other than English can be recommended to provide more detailed results about diverse cultural perspectives on selfmanagement strategies for stroke rehabilitation. Moreover, our review also excluded literature reporting studies conducted in children (<18 years of age) due to stroke in children being relatively rare (1.3-13 in 100,000 children). 66 In addition, there was a lack of information on study participants (e.g. stroke severity, gender, and age).

Future directions
Given the importance of self-management in stroke rehabilitation, research is required to determine how to promote self-management among stroke survivors. Considering the importance of formal and informal caregivers, future research should focus on including them in self-management implementation and advance existing selfmanagement strategies based their experiences and opinions. Also, to determine the effectiveness of varied self-management strategies in improving stroke survivors' functional capacity, mental health, and everyday activities, large-scale studies examining the stroke survivors' quality of life and health services use are needed.

Conclusions
This scoping review provides an important overview on stroke survivors' use of self-management strategies and their experience. Their use of selfmanagement strategies is complicated and multifaceted, comprising several domains and involving a diverse range of approaches and personal experiences. However, there is no available rigorous evidence regarding the prevalence rates of commonly used self-management strategies post stroke, the profile of such users, as well as the long-term effects of those strategies over the course of a stroke survivor's life and treatment journey. Therefore, more research is required on the use of self-management strategies for stroke rehabilitation.

Funding
The author(s) reported there is no funding associated with the work featured in this article.

Ethical approval
Ethical approval is not applicable for this literature review.

Availability of data and materials
The data used in this study are available from the corresponding author, upon reasonable request.