NIHR Signal Supported self-management improves quality of life and self-belief after stroke

Published on 1 November 2016

Training people to take an active role in managing the consequences of their stroke improves their quality of life.

These self-management programmes are usually led by health professionals. They cover a range of skills including problem solving, goal setting, and decision-making and provide advice about stroke. The improvement appears to act through “self-belief”. For example, promoting independence in people appeared to foster a greater belief in their own abilities.

This Cochrane review pooled data from 14 trials comparing supported self-management with control interventions in people who had experienced a stroke one month to a year previously and lived in the community. Participants varied in their level of disability after stroke.

These findings from a well conducted review support the principles that people with stroke should take an active role in their on-going care and receive training in how to manage everyday activities.

Further research is needed to determine the ideal format, duration and frequency of self-management sessions. The cost effectiveness of self-management also needs to be assessed.

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Why was this study needed?

Around 1.2 million people in the UK have had a stroke, and more than half have been left with a disability. The long-term effects of stroke can limit people’s ability to live independently, affecting their quality of life and increase rates of anxiety and depression.

Self-management programmes help people living with chronic diseases to take an active role in managing their illness. These programmes teach a range of skills such as problem solving, goal setting and constructing action plans for specific tasks. The aim is to help participants feel more confident that they will be able to accomplish certain tasks, known as self-efficacy.

In people with stroke, higher self-efficacy has been associated with better quality of life, improved ability to perform everyday activities and lower likelihood of depression. This review investigated if self-management programmes influence self-efficacy after stroke and if this can lead to positive outcomes.

What did this study do?

This Cochrane systematic review included 14 randomised controlled trials (four from the UK) of self-management programmes in adults with stroke.

Self-management programmes varied across studies but tended to involve stroke-related education, problem identification, reinforcing resources and capabilities, self-efficacy and control, goal setting, problem solving, social support and stress management. Self-management was compared with either an active control (for example, stroke education) or an inactive control (for example, waiting list or usual care). Interventions lasted from one to six months. Different formats of programme support were given, from group sessions to one-to-one support. The professional background in those delivering self-management support varied, with the majority being allied health professionals, some with peer trainers.

The 1,863 participants were all living in the community one month to a year after stroke. Type of stroke varied among participants, as did the associated impairment.

The majority of the studies were well conducted and represent credible evidence.

What did it find?

  • People who undertook self-management had significantly better quality of life than those who received an active or inactive control (standardised mean difference [SMD] 0.34, 95% confidence interval [CI] 0.05 to 0.62). This analysis pooled six moderate quality trials with 469 participants.
  • Self-efficacy was also significantly better in people who received self-management compared with controls (SMD 0.33, 95% CI 0.04 to 0.61). This analysis used six low quality trials (403 participants), meaning we have less confidence in the size of this effect.
  • Self-management was not significantly associated with better ability to move or complete everyday activities (SMD 0.22, 95% CI -0.03 to 0.46; four moderate quality trials, 260 participants).
  • Anxiety and depression were also not significantly better in people on self-management compared with controls (mean difference -0.56, 95% CI -1.27 to 0.15; six low quality trials, 648 participants).

What does current guidance say on this issue?

The 2013 NICE guideline on stroke rehabilitation in adults recommends that people with stroke should have rehabilitation goals that focus on activity and participation, are challenging but achievable, and have meaning and relevance for them. Goal-setting meetings should be multidisciplinary and involve the person with stroke and, where appropriate, their family or carer. As a starting point, 45 minute rehabilitation sessions are recommended on at least five days a week.

What are the implications?

Offering self-management programmes to people who have had a stroke may empower them to take charge of their lives. These programmes could help people live independently after hospital discharge, and improve their quality of life.

The review only found a non-significant trend to improve mood (reduce anxiety and depression) and improve independence in activities. Despite this, these are well recognised goals after stroke and should probably still be addressed in these types of programmes, pending better evidence.

This review did not investigate whether self-management is cost effective for people with stroke who live in the community. However other literature on self-management support for non-stroke conditions show a potential for such interventions to save costs without compromising patient outcomes.

Those working in the field will have further insights into the ideal format, duration and frequency of self-management sessions relative to the individual’s needs and level of impairment.

For implementing such programmes at scale commissioners would need to know more about the key features of the programmes that are linked to success. For example, what are the ideal frequency, duration, and mode of sessions? And what are the overall costs?

Citation and Funding

Fryer CE, Luker JA, McDonnell MN, Hillier SL. Self management programmes for quality of life in people with stroke. Cochrane Database Syst Rev. 2016;8:CD010442.

No funding information was provided for this study.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2014.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

Panagioti M, Richardson G, Small N, et al. Self-management support interventions to reduce health care utilisation without compromising outcomes: a systematic review and meta-analysis. BMC Health Services Research. 2014 Aug 27;14(1):1.

Stroke Association. State of the Nation: stroke statistics. London: Stroke Association; 2016.

Why was this study needed?

Around 1.2 million people in the UK have had a stroke, and more than half have been left with a disability. The long-term effects of stroke can limit people’s ability to live independently, affecting their quality of life and increase rates of anxiety and depression.

Self-management programmes help people living with chronic diseases to take an active role in managing their illness. These programmes teach a range of skills such as problem solving, goal setting and constructing action plans for specific tasks. The aim is to help participants feel more confident that they will be able to accomplish certain tasks, known as self-efficacy.

In people with stroke, higher self-efficacy has been associated with better quality of life, improved ability to perform everyday activities and lower likelihood of depression. This review investigated if self-management programmes influence self-efficacy after stroke and if this can lead to positive outcomes.

What did this study do?

This Cochrane systematic review included 14 randomised controlled trials (four from the UK) of self-management programmes in adults with stroke.

Self-management programmes varied across studies but tended to involve stroke-related education, problem identification, reinforcing resources and capabilities, self-efficacy and control, goal setting, problem solving, social support and stress management. Self-management was compared with either an active control (for example, stroke education) or an inactive control (for example, waiting list or usual care). Interventions lasted from one to six months. Different formats of programme support were given, from group sessions to one-to-one support. The professional background in those delivering self-management support varied, with the majority being allied health professionals, some with peer trainers.

The 1,863 participants were all living in the community one month to a year after stroke. Type of stroke varied among participants, as did the associated impairment.

The majority of the studies were well conducted and represent credible evidence.

What did it find?

  • People who undertook self-management had significantly better quality of life than those who received an active or inactive control (standardised mean difference [SMD] 0.34, 95% confidence interval [CI] 0.05 to 0.62). This analysis pooled six moderate quality trials with 469 participants.
  • Self-efficacy was also significantly better in people who received self-management compared with controls (SMD 0.33, 95% CI 0.04 to 0.61). This analysis used six low quality trials (403 participants), meaning we have less confidence in the size of this effect.
  • Self-management was not significantly associated with better ability to move or complete everyday activities (SMD 0.22, 95% CI -0.03 to 0.46; four moderate quality trials, 260 participants).
  • Anxiety and depression were also not significantly better in people on self-management compared with controls (mean difference -0.56, 95% CI -1.27 to 0.15; six low quality trials, 648 participants).

What does current guidance say on this issue?

The 2013 NICE guideline on stroke rehabilitation in adults recommends that people with stroke should have rehabilitation goals that focus on activity and participation, are challenging but achievable, and have meaning and relevance for them. Goal-setting meetings should be multidisciplinary and involve the person with stroke and, where appropriate, their family or carer. As a starting point, 45 minute rehabilitation sessions are recommended on at least five days a week.

What are the implications?

Offering self-management programmes to people who have had a stroke may empower them to take charge of their lives. These programmes could help people live independently after hospital discharge, and improve their quality of life.

The review only found a non-significant trend to improve mood (reduce anxiety and depression) and improve independence in activities. Despite this, these are well recognised goals after stroke and should probably still be addressed in these types of programmes, pending better evidence.

This review did not investigate whether self-management is cost effective for people with stroke who live in the community. However other literature on self-management support for non-stroke conditions show a potential for such interventions to save costs without compromising patient outcomes.

Those working in the field will have further insights into the ideal format, duration and frequency of self-management sessions relative to the individual’s needs and level of impairment.

For implementing such programmes at scale commissioners would need to know more about the key features of the programmes that are linked to success. For example, what are the ideal frequency, duration, and mode of sessions? And what are the overall costs?

Citation and Funding

Fryer CE, Luker JA, McDonnell MN, Hillier SL. Self management programmes for quality of life in people with stroke. Cochrane Database Syst Rev. 2016;8:CD010442.

No funding information was provided for this study.

Bibliography

NHS Choices. Stroke. London: Department of Health; 2014.

NICE. Stroke rehabilitation in adults. CG162. London: National Institute for Health and Care Excellence; 2013.

Panagioti M, Richardson G, Small N, et al. Self-management support interventions to reduce health care utilisation without compromising outcomes: a systematic review and meta-analysis. BMC Health Services Research. 2014 Aug 27;14(1):1.

Stroke Association. State of the Nation: stroke statistics. London: Stroke Association; 2016.

Self management programmes for quality of life in people with stroke

Published on 23 August 2016

Fryer, C. E.,Luker, J. A.,McDonnell, M. N.,Hillier, S. L.

Cochrane Database Syst Rev Volume 8 , 2016

BACKGROUND: Stroke results from an acute lack of blood supply to the brain and becomes a chronic health condition for millions of survivors around the world. Self management can offer stroke survivors a pathway to promote their recovery. Self management programmes for people with stroke can include specific education about the stroke and likely effects but essentially, also focusses on skills training to encourage people to take an active part in their management. Such skills training can include problem-solving, goal-setting, decision-making, and coping skills. OBJECTIVES: To assess the effects of self management interventions on the quality of life of adults with stroke who are living in the community, compared with inactive or active (usual care) control interventions. SEARCH METHODS: We searched the following databases from inception to April 2016: the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, OTSeeker, OT Search, PEDro, REHABDATA, and DARE. We also searched the following trial registries: ClinicalTrials.gov, Stroke Trials Registry, Current Controlled Trials, World Health Organization, and Australian New Zealand Clinical Trials Registry. SELECTION CRITERIA: We included randomised controlled trials of adults with stroke living in the community who received self management interventions. These interventions included more than one component of self management or targeted more than a single domain of change, or both. Interventions were compared with either an inactive control (waiting list or usual care) or active control (alternate intervention such as education only). Measured outcomes included changes in quality of life, self efficacy, activity or participation levels, impairments, health service usage, health behaviours (such as medication adherence or lifestyle behaviours), cost, participant satisfaction, or adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted prespecified data from all included studies and assessed trial quality and risk of bias. We performed meta-analyses where possible to pool results. MAIN RESULTS: We included 14 trials with 1863 participants. Evidence from six studies showed that self management programmes improved quality of life in people with stroke (standardised mean difference (SMD) random effects 0.34, 95% confidence interval (CI) 0.05 to 0.62, P = 0.02; moderate quality evidence) and improved self efficacy (SMD, random effects 0.33, 95% CI 0.04 to 0.61, P = 0.03; low quality evidence) compared with usual care. Individual studies reported benefits for health-related behaviours such as reduced use of health services, smoking, and alcohol intake, as well as improved diet and attitude. However, there was no superior effect for such programmes in the domains of locus of control, activities of daily living, medication adherence, participation, or mood. Statistical heterogeneity was mostly low; however, there was much variation in the types and delivery of programmes. Risk of bias was relatively low for complex intervention clinical trials where participants and personnel could not be blinded. AUTHORS' CONCLUSIONS: The current evidence indicates that self management programmes may benefit people with stroke who are living in the community. The benefits of such programmes lie in improved quality of life and self efficacy. These are all well-recognised goals for people after stroke. There is evidence for many modes of delivery and examples of tailoring content to the target group. Leaders were usually professionals but peers (stroke survivors and carers) were also reported - the commonality is being trained and expert in stroke and its consequences. It would be beneficial for further research to be focused on identifying key features of effective self management programmes and assessing their cost-effectiveness.

Self-efficacy describes a person’s expectation that they are capable of performing particular tasks or behaviours to produce a given outcome – for example, feeling that one can complete a plan one has made. This expectation reflects a person’s perceived, rather than actual, capabilities.

Expert commentary

Self-management for most stroke survivors has meant muddling along long term without expert learning support. This study shows that properly crafted support and structure for self-management can make a positive difference in terms of quality of life and much health-related behaviour. With interactive information technology now widely accessible innovative new programmes such as the Stroke Association’s My Stroke Guide should become a key component of a structured return to independent and supported living. This study scratches at the surface of the possibilities for engaging the stroke survivor and their carers in recovery and deserves praise for prompting thinking about the need for greater future innovation and research that can provide rigour and application of evidence based techniques, basic to empowering patients.

Jon Barrick, President, Stroke Alliance for Europe (coalition of 30 stroke patient national organisations)