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NIHR Signal Self-management support for stroke survivors may improve independence

Published on 19 October 2015

doi: 10.3310/signal-000134

This NIHR-funded summary of systematic reviews looked at the evidence on self-management support for stroke survivors. It found that the term self-management was rarely used in the literature. There was high quality evidence that therapy-based rehabilitation, some of it including components supporting self-management, had a beneficial effect on the basic activities of daily living, such as feeding, bathing and dressing and extended activities, such as shopping. Self-management support is a less well established aspect of care for people after stroke, in contrast to its established role for other long-term conditions like diabetes. These researchers looked in detail at the description of rehabilitation activities provided in a range of reviews with a focus on the self-management support found useful for other conditions. These included things like, information provision, improving self-confidence, solving problems for caregivers and increasing participation in decisions. It found that post-stroke rehabilitation services currently deliver some elements of self-management support, even if they are not labelled as such. Commissioners and healthcare providers could consider actively promoting support interventions as part of the usual care to empower people following stroke. This may help them with the skills required for managing the medical, emotional and social aspects of their lives.

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Why was this study needed?

Although stroke death rates are in decline, stroke is still a major problem in the UK. Each year more than 120,000 people in the UK have a stroke. More than 900,000 people live with the consequences of stroke and about half of these have disability that means they need assistance with tasks of daily life. With an aging population the burden of stroke is likely to increase in the future.

The NIHR funded this study on interventions supporting self-management in stroke survivors to inform commissioners and healthcare providers of what works, for whom, and in what contexts. This was part of a larger project investigating self-management support interventions for people with a range of long-term conditions including asthma, diabetes and depression.

What did this study do?

This study analysed existing systematic reviews looking at interventions to support self-management for people who have survived stroke. The systematic reviews included randomised controlled trials of strategies to support self-management delivered to stroke survivors or their caregivers. The quality of the systematic reviews was assessed and scored to inform the weighting of the evidence. Thirteen systematic reviews were selected including 101 trials.

Seven reviews explored interventions based on rehabilitation delivered by occupational therapists or physiotherapists. The other reviews looked at self-management support interventions including information provision, improving self-efficacy (self-confidence), caregiver problem solving, and increasing participation in healthcare. As a summary of systematic reviews, it was not possible to pool the results of underlying primary studies, but despite the complexity of the topic the researchers did extract details of the self-management components offered. They then provided a description of what has potential in helping people to look after themselves after stroke.

What did it find?

  • The term self-management was rarely used to describe the interventions for support which varied across the included trials. Key elements, such as goal setting and problem solving were present as components of many therapy interventions.
  • High-quality evidence from six reviews showed that therapy-based rehabilitation, delivered in the early period of stroke recovery, had a short term (five weeks to a year) beneficial effect on activities of daily living (e.g. feeding, bathing and dressing) and extended activities (e.g. shopping, cooking and use of transportation). It was not possible to meta-analyse results.
  • One review looking at therapy-based rehabilitation given one year after stroke found no improvements in activities of daily living though another found improvement in extended activities of daily living.
  • Two reasonable quality reviews found evidence that therapy-based rehabilitation improved community reintegration.

What does current guidance say on this issue?

The 2013 NICE guideline on stroke rehabilitation recommends that occupational therapy should be provided to address difficulties with personal activities of daily living, but does not explicitly mention any interventions that aim to promote self-management.

The 2012 Royal College of Physicians national clinical guideline for stroke recommends that all patients should be offered training in self-management skills, including active problem-solving and individual goal setting.

What are the implications?

Therapy-based rehabilitation for stroke survivors provided by health professionals such as occupational or physiotherapists currently delivers elements of self-management support. Commissioners and providers could consider how to actively support self-management as part of usual care for people with stroke or their carers. Support interventions provided early in the post-stroke recovery period are best designed to address the medical, emotional and role management aspects of stroke survivors’ lives. Ultimately this support aims to increase the independence that is valued by stroke survivors.

Citation

Parke HL, Epiphaniou E, Pearce G, et al. Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review. PLoS ONE. 2015; 10(7): e0131448.

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 11/1014/04).

Bibliography

NICE. Stroke rehabilitation: long-term rehabilitation after stroke. CG 162. London: National Institute for Health and Care Excellence; 2013.

NICE. Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). CG 68. London: National Institute for Health and Care Excellence; 2008.

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians; 2012.

Taylor SJC, Pinnock H, Epiphaniou E, et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic Review of Self-Management Support for long-term conditions. NIHR Journals Library: Health Services and Delivery Research. 2014;2(53).

Why was this study needed?

Although stroke death rates are in decline, stroke is still a major problem in the UK. Each year more than 120,000 people in the UK have a stroke. More than 900,000 people live with the consequences of stroke and about half of these have disability that means they need assistance with tasks of daily life. With an aging population the burden of stroke is likely to increase in the future.

The NIHR funded this study on interventions supporting self-management in stroke survivors to inform commissioners and healthcare providers of what works, for whom, and in what contexts. This was part of a larger project investigating self-management support interventions for people with a range of long-term conditions including asthma, diabetes and depression.

What did this study do?

This study analysed existing systematic reviews looking at interventions to support self-management for people who have survived stroke. The systematic reviews included randomised controlled trials of strategies to support self-management delivered to stroke survivors or their caregivers. The quality of the systematic reviews was assessed and scored to inform the weighting of the evidence. Thirteen systematic reviews were selected including 101 trials.

Seven reviews explored interventions based on rehabilitation delivered by occupational therapists or physiotherapists. The other reviews looked at self-management support interventions including information provision, improving self-efficacy (self-confidence), caregiver problem solving, and increasing participation in healthcare. As a summary of systematic reviews, it was not possible to pool the results of underlying primary studies, but despite the complexity of the topic the researchers did extract details of the self-management components offered. They then provided a description of what has potential in helping people to look after themselves after stroke.

What did it find?

  • The term self-management was rarely used to describe the interventions for support which varied across the included trials. Key elements, such as goal setting and problem solving were present as components of many therapy interventions.
  • High-quality evidence from six reviews showed that therapy-based rehabilitation, delivered in the early period of stroke recovery, had a short term (five weeks to a year) beneficial effect on activities of daily living (e.g. feeding, bathing and dressing) and extended activities (e.g. shopping, cooking and use of transportation). It was not possible to meta-analyse results.
  • One review looking at therapy-based rehabilitation given one year after stroke found no improvements in activities of daily living though another found improvement in extended activities of daily living.
  • Two reasonable quality reviews found evidence that therapy-based rehabilitation improved community reintegration.

What does current guidance say on this issue?

The 2013 NICE guideline on stroke rehabilitation recommends that occupational therapy should be provided to address difficulties with personal activities of daily living, but does not explicitly mention any interventions that aim to promote self-management.

The 2012 Royal College of Physicians national clinical guideline for stroke recommends that all patients should be offered training in self-management skills, including active problem-solving and individual goal setting.

What are the implications?

Therapy-based rehabilitation for stroke survivors provided by health professionals such as occupational or physiotherapists currently delivers elements of self-management support. Commissioners and providers could consider how to actively support self-management as part of usual care for people with stroke or their carers. Support interventions provided early in the post-stroke recovery period are best designed to address the medical, emotional and role management aspects of stroke survivors’ lives. Ultimately this support aims to increase the independence that is valued by stroke survivors.

Citation

Parke HL, Epiphaniou E, Pearce G, et al. Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review. PLoS ONE. 2015; 10(7): e0131448.

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 11/1014/04).

Bibliography

NICE. Stroke rehabilitation: long-term rehabilitation after stroke. CG 162. London: National Institute for Health and Care Excellence; 2013.

NICE. Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). CG 68. London: National Institute for Health and Care Excellence; 2008.

Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians; 2012.

Taylor SJC, Pinnock H, Epiphaniou E, et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic Review of Self-Management Support for long-term conditions. NIHR Journals Library: Health Services and Delivery Research. 2014;2(53).

Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review

Published on 24 July 2015

Parke, H. L.,Epiphaniou, E.,Pearce, G.,Taylor, S. J.,Sheikh, A.,Griffiths, C. J.,Greenhalgh, T.,Pinnock, H.

PLoS One Volume 10 , 2015

BACKGROUND: There is considerable policy interest in promoting self-management in patients with long-term conditions, but it remains uncertain whether these interventions are effective in stroke patients. DESIGN: Systematic meta-review of the evidence for self-management support interventions with stroke survivors to inform provision of healthcare services. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, BNI, Database of Abstracts of Reviews for Effectiveness, and Cochrane Database of Systematic Reviews for systematic reviews of self-management support interventions for stroke survivors. Quality was assessed using the R-AMSTAR tool, and data extracted using a customised data extraction form. We undertook a narrative synthesis of the reviews' findings. RESULTS: From 12,400 titles we selected 13 systematic reviews (published 2003-2012) representing 101 individual trials. Although the term 'self-management' was rarely used, key elements of self-management support such as goal setting, action planning, and problem solving were core components of therapy rehabilitation interventions. We found high quality evidence that supported self-management in the context of therapy rehabilitation delivered soon after the stroke event resulted in short-term (< 1 year) improvements in basic and extended activities of daily living, and a reduction in poor outcomes (dependence/death). There is some evidence that rehabilitation and problem solving interventions facilitated reintegration into the community. CONCLUSIONS: Self-management terminology is rarely used in the context of stroke. However, therapy rehabilitation currently successfully delivers elements of self-management support to stroke survivors and their caregivers with improved outcomes. Future research should focus on managing the emotional, medical and social tasks of long-term survivorship.

The definition of self-management proposed by the US Institute of Medicine was adopted for this review: “Self-management is defined as the task that individuals must undertake to live with one or more chronic conditions. These tasks include the confidence to deal with medical management, role management and emotional management of their conditions.”

Self-management support is not meant to be a substitute for professional care. It aims to empower people with the skills to manage medical tasks such as secondary stroke prevention, be able to perform functions of daily life, reintegrate into their community and deal with the emotional impact of stroke such as post-stroke depression.

Expert commentary

Are self-management support interventions effective for stroke survivors? This meta-review looked for systematic reviews of such interventions but found that the term self-management was rarely used. Creatively, the authors included reviews of standard interventions employing components of self-management, such as goal setting. The evidence reported is important, in the guidelines and limited: stroke patients benefit from early rehabilitation therapies. But how much of acute stroke rehabilitation could be considered ‘self-management’? It is sometimes the case that self-management terminology is used simply to promote patient compliance with professional goals. Recent and on-going research is investigating whether therapists can integrate self-management strategies into their care, and with what results for stroke patients. Some examples of the reviews the authors originally sought have recently been published.

Christopher McKevitt, Professor of Social Science and Health, King’s College London

Author commentary

The promotion of self-management is an important national policy for managing the increasing number of people living with long-term conditions, although self-management terminology is rarely used in the research literature around stroke. Our systematic review found that therapy rehabilitation currently successfully delivers some elements of self-management support to stroke survivors. We therefore offer the novel suggestion that therapy rehabilitation may offer a foundation on which new ideas around self-management for stroke survivors can build to embrace the wider and longer-term psychological and social aspects of self-management.

Dr Hilary Pinnock, Usher Institute of Medical Informatics and Population Health Sciences, University of Edinburgh