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

Article Reviews
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Read Full Text: Self-Management Support Interventions for Stroke Survivors: A Systematic Meta-Review (Free to access)
Journal: PLoS One
Year Published: 2015
Ranked 82nd on our 2015-2020 list of the 100 most influential OT-related articles
CEU Podcast: Self-Management for Stroke with Lauren Sheehan

I’m always curious if there is a more straightforward way to describe the goals of occupational therapy—terms like “occupational performance” don’t really resonate with our patients.

That’s why I was intrigued by the concept explored in this week’s article: self-management.

In this article, you’ll find that much of the “self-management” research the authors studied was actually OT research! Plus, the outcomes were quite promising. Whether you work with stroke patients or not, this is a conversation you’ll definitely want to follow.

Let’s dive in.

Why is the concept of self-management so important to consider for stroke care?

There’s bad news and good news regarding the care of patients post-stroke.

The bad news is that stroke occurrence is on the rise: as many as one in 20 adults suffers a cerebrovascular infarction (CVA). Notably, stroke occurrence has increased significantly in low- and middle-income countries, but decreased in high-income countries.

The good news is that medical advances are leading to much higher survival rates.

Unfortunately, there’s more bad news: one in three stroke survivors suffers permanent disability, which not only dramatically disrupts their lives, but also places a burden on our healthcare systems.

The concept of self-management has been explored in depth regarding long-term conditions like asthma and diabetes. However, self-management in patients post-stroke has only just begun to garner considerable interest from a policy and research perspective. In fact, this week’s study is the first I’ve seen that really delves into the idea of self-management among stroke survivors.

Self-management seems like a big topic— what does it actually include?

Self-management simply refers to undertaking necessary tasks required to live with a chronic condition. These tasks include:

  • Medical management
  • Role management
  • Emotional management

Five core skills that enable self-management have been identified:

  1. Problem-solving
  2. Decision-making
  3. Appropriate resource utilization
  4. Forming a partnership with a healthcare provider
  5. Taking necessary action

Self-efficacy is commonly viewed as the quality that helps bridge the gap between patients learning self-management skills—and actually carrying them out.

What did the authors hope to contribute to the research on stroke and self-management?

For those of you interested in advocacy, this article is for you. The article was commissioned to help inform both clinicians and healthcare systems that are seeking to promote self-management for stroke survivors.

This article is part of a larger review of self-management, which was undertaken by the UK’s Health Services and Delivery Research (HS&DR) Programme.

How was this research conducted?

This was a systematic meta-review, which is basically a systematic review of other systematic reviews. As you might imagine, this type of research sits at the very top of our evidence pyramid. :slight_smile:

13 reviews were ultimately chosen for inclusion in this meta-review. The included reviews studied 101 individual randomized controlled trials (RCTs).

What types of reviews did they examine?

All reviews contained self-management supports for stroke survivors. (The authors searched for supports such as: problem solving, goal setting, supports for adaptive equipment, remediation training, liaising with other services, and training in ADLs.)

7 reviews explored interventions based on rehab therapy. (4 of these were exclusive to OT!)

6 reviews looked at various self-management support interventions, including: referral to stroke liaison workers, information provision, self-efficacy enhancement, patient-held records, and caregiver problem solving.

What outcome measures/assessments did they find?

Because there were 101 studies included in this meta-review, there were A LOT of assessments involved. I’m going to take the time to list them, because so many are relevant to OT.

Primary Activities of Daily Living

Extended Activities of Daily Living

Self Efficacy

Community Integration

Quality of Life

Cognitive Function

Mood

Compliance

What were the results?

Given the wide range of studies the researchers examined, the results were, of course, nuanced.

So, I highly encourage you to read the article in its entirety.

But, overall, when it came to rehab therapy with a self-management component, the results were promising. In fact, the researchers even broke the results down into a handy checklist, which included the following:

The available systematic review evidence suggests the following MAY work:

  • High-quality, strong evidence suggests that therapy rehabilitation delivered in the early phase of stroke has a positive effect on activities of daily living (ADLs) and extended ADLs—and it shows a reduction in poor outcomes (dependence and death).
  • Reasonable quality reviews provide some evidence that therapy rehabilitation delivered later in stroke recovery has a beneficial effect on extended ADLs—and it also shows a reduction in poor outcomes (dependence and death).

The available systematic review evidence suggests the following are UNLIKELY to work:

  • High-quality, strong evidence suggests that therapy rehabilitation has NO impact on mood.
  • Some evidence from high-quality reviews suggests that therapy rehabilitation delivered later in stroke recovery has NO impact on ADLs or quality of life.

What did the authors conclude/discuss?

The authors concluded that even though the term “self-management” is rarely used in stroke research, therapy rehabilitation is already successfully delivering elements of self-management to help survivors and their caregivers achieve improved outcomes.

The authors (who represented backgrounds in primary care, public health, and health psychology) really honed in on how OT, specifically, aligns with foundations of self-management. They highlighted occupational therapy’s focus on forming a strong patient/provider partnership (self-management core skill #4) and they noted that promoting patients’ self-efficacy is one of our stated goals.

Finally they ended by emphasizing that self-management requires a whole systems approach, in which a healthcare system promotes collaborative relationships between patients and health professionals.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1. We are already leaders in promoting self-management—and this article sheds light on how we can expand and own that role.

Whether we knew it or not, reading this article makes it clear that OT is a leader in self-management for stroke; we are uniquely qualified to be leaders in the future of self care. When it comes to the tasks, we clearly excel at helping patients think about role management. This article really pushed me to think about how we can more explicitly tackle medical management and emotional management, along with the 5 core skills of self-management.

2. Perhaps a simple shift in the language we use could help us better connect with our team and our clients.

What a treat it was to read researchers from outside our profession describing the benefits of OT! In fact, it got me wondering if our OT community could learn something from how they explained our profession. The article made me wonder if simply using the term “self-management” more to describe our OT work might help our patients (not to mention, the entire healthcare team) better understand what we do. Afterall, “self-management” is a concept that is intuitive and easy to understand, when so much of our medical jargon leaves our patients (and coworkers) confused.

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with stroke care expert (and Club member!), Lauren Sheehan. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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This is really very interesting! It puts evidence behind what I’ve learned over the years with stroke recovery. I like the idea of using the words Self management because that is totally what OT is doing - teaching stroke survivors how to facilitate the rest of their life and be their own advocates!

Question though. I don’t see the difference here between these 2 interventions.

Reasonable quality reviews provide some evidence that therapy rehabilitation delivered later in stroke recovery has a beneficial effect on extended ADLs—and it also shows a reduction in poor outcomes (dependence and death).

AND

Some evidence from high-quality reviews suggests that therapy rehabilitation delivered later in stroke recovery has NO impact on ADLs or quality of life.

Is it that the first one is talking specifically about extended ADLs which I’m guessing are IADLs and the second is talking about basic ADLs?

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Also I am REALLY looking forward to this as a podcast for hopefully more nuanced discussion!

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Sarah,
Great article and one that really supports the core of occupational therapy practice ( ADL, IADL, self-management, and QoL.)

As I read the article the summaries at the end of the article stood out to me. Positive Stroke outcomes Less evidence and less support

My take away here is the ‘window of opportunity.’ Outcomes are more effective immediately after the stroke and are less effective later in the recovery process mirroring what we discovered last week related to neuroplasticity and recovery using CMIT and bimanual activities in children.

Great article.

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Hey @BrandyA!! I can’t wait to get your feedback on our podcast. I think you will appreciate the guest (Lauren Sheehan @lauren2 :-))!

Thanks for calling out the confusing findings. I had to read them multiple times to understand them!

In the evidence they looked at therapy delivered later in stroke seemed to have a beneficial effect on EXTENDED ADLs, but no impact on ADLs.

The later in stroke therapy also reduced poor outcomes (which was basically death and dependence). But an impact was not seen on their quality of life measures.

I thought it made sense that during the chronic phase of stroke that therapy was most beneficial for EXTENDED ADLS. However the fact that there was no benefit seen in the quality of life measurements, made me questions whether the assessments they were using were sensitive enough…

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Oh great! Lauren is awesome and has so much knowledge on post acute CVA treatments.

So are extended ADLs things like cooking, driving, working?

If so, those seem to be the things that significantly impact quality of life, at least from my unofficial qualitative analysis of my own patients. I’m surprised too that they did not find a change in quality of life scores…

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Wow, Sarah, another great article on my favorite topic. Yes, I too was very excited seeing OT intervention activities cited by people outside our profession.
The article does validate all we do as OTs and provides added affirmation to “neuroplasticity and starting therapy ASAP after a stroke”.(Self-management is a such an appropriate term for chronic stroke- guess I never thought of it in that way).
Some findings surprised me - High-quality strong evidence and reasonable quality evidence showed that though therapy rehab (both early and late) had a positive impact on ADLs and IADLs, it had no impact on mood. One would aptly think that if you regain independence in daily living tasks, you would be happier. More food for thought.

I want to thank you for the various links provided within this article. The links took me to more person-centered, occupation-based articles (RCT) done internationally by OTs on other chronic diseases.
I am eagerly waiting for the Podcast next week.

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@sanchala, @BrandyA, @sherry I am so excited/nervous for OTs I admire so much (you all!) to listen to the podcast. :slight_smile: I would love your honest feedback once it become available.

I’ve been thinking today about some of the seemingly inconsistent results from this systematic review, (like if death and dependency is decreased how could quality of life NOT be increased…) I think this all comes back to the imperfect nature of a systematic review that looks at such varied studies. I’m hopeful that over the years that self-management of stroke will turn into a more systematic approach to stroke care, and as a result we will see better research.

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@SarahLyon Thank you for providing this run-down. I agree that this is definitely an approach we can take to increasing clients understanding of what our role as OT’s is. Funnily enough, since starting in my role as a sole rural OT (Australia) I have found there is a significant gap in understanding of what OT is; even among other allied health/health professionals. I have always joked/remarked that “my job is to put myself out of the job” without fully realising what I am promoting is the complex idea of self-management.

It is really nice to have a bit more evidence and information to put behind my explanation to my clients. I really look forward to listening into the podcast.

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That’s funny! I say that phrase too! :joy:

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@BrandyA, nice to see you here!! Although Sarah and I didn’t talk about this specifically on the podcast, I’m wondering whether the reason we don’t see changes in ADLs (and I took it to mean basic ADLs as well) a certain time into the chronic phase of stroke, is that we’re not focusing our interventions on aspects of self management, generally speaking. It’s been my experience that it’s difficult to change routines in chronic stroke because many folks have settled into their ADLs with a certain amount of assistance and sometimes have difficulty getting beyond those routines. Practicing the tasks themselves doesn’t move the needle much if the patient doesn’t have the motivation or self efficacy to take on these new tasks. Elements of self management are so important to making lasting change in chronic stroke because it’s about the “how” not the “what” as we talk about on the podcast. So curious to get your feedback!!

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In my last year of school, we had a guest speaker who runs a self-management program throughout Southern Ontario. It was so interesting! I actually gave their program book to a family member with chronic health conditions as a gift afterwards.

There is definitely a role for OT in the direct self-management approach because self-management isn’t a one size fits all method. The OT perspective would fit really well into tailoring long term habits for self-management to assist in wellness after rehabilitation is completed.

I only worked briefly in Stroke Rehab as my earliest placement in school, but I can see how a focus on self-managing ones own wellness would shape the overall care program in a positive way. Anything that promotes self-efficacy and adherence is in the right direction in my experience, from young kids with CO-OP to older adults with self-management goals. It would be interesting to see what the practical results would be from developing habits within care, with support, for the individuals long-term plan for supporting their wellness after-care.

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On a personal note, this spring my mother-in-law was receiving home OT services and I had to advocate for self-management services related to her Diabetes, HTN, and her finances.My MIL had been hospitalized for high blood pressure and her medication was changed. She would not listen to my husband and I regarding monitoring her blood pressure in a log as well as sugar levels. She also was doing all the finances for the first time in 68 years as my FIL was ill. When talking to the OT about my concerns she indicated the referral did not include these areas. There appears to be a need to educate referral sources on the depth of OT services.

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This is the first article I’m adding to my EBP portfolio! I’m excited to continue this journey in “lifelong learning” after graduating in December :slight_smile:

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Wow! That is so awesome!! I wish that I has started an EBP portfolio when I graduated!!! When you find out what setting you end up working in feel free to shoot me a message, and I can help brainstorm any other evidence we’ve read that would be good for you to add to the portfolio!

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Thanks for sharing this, @sherry. I’m glad you were able to be there to advocate for your mother-in-law, but sorry that you hit some roadblocks to getting her the help she needed.

I’ve been thinking about all of the barriers to working more explicitly toward self-management, and i hadn’t thought of the MD order. While, it seems like an easy fix to get an MD to write an order for OT to address ADL and iADL deficits, I know it can be challenging to change habits and systems that have become routine. This is yet another reason we need to be regularly in contact with the MDs we work with frequently… and why working on management truly takes the whole team being on board.

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Thanks for reaching out! I’m so glad I stumbled upon this club! I am currently working PRN in skilled nursing care providing intermittent evaluations and treatments. If you have any information on best treatments for successful outcomes with hard to motivate, sedentary older adults and seniors, that would be amazing! Also any info you have on treatment plan development and progression would be greatly appreciated! Thanks again

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Awesome article! As a peds OT, there is a lot of discussion lately regarding two similar ideas. One is children helping to create their own goals. A lot of the discussion leading up to those self determined goals are so similar to the identified 5 core skills. I’m also thinking a lot about family coaching, which is over and over talked about as a best practice in early childhood. Coaching is, in many ways, helping families work through those five skills and be able to ‘self-manage’ their child’s needs. So much applicability here - great review!

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@SarahLyon, this article is very relevant in the world of therapy as we OTs see so many stroke survivors. In rural areas, such as much of Nebraska, there has already been an identified disparity between stroke survivors’ care compared to metropolitan areas. This article brings great awareness on how to help stroke survivors to be self sufficient, especially those that live in areas with fewer resources and fewer support that rely on self management skills. This article also brings great awareness of what OTs that deliver care via telehealth should prioritize with stroke survivors.

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