Evidence
Alert

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

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.

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.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

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.

Commentaries

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)