The Effect of Self-Management Education Following Mild Stroke: An Exploratory Randomized Controlled Trial

PURPOSE: The purpose of this pilot study was to determine if a self-management intervention, the Chronic Disease Self-Management Program (CDSMP), is feasible and can have an effect on health outcomes in individuals with mild stroke. Stroke is the leading cause of long-term disability in the United States, with mild stroke accounting for 53% of stroke hospital admissions. However, 57% of mild stroke patients receive no rehabilitation services upon discharge (Wolf, Baum, & Connor, 2009). Often, a mild stroke is the first warning sign of risk factors (e.g., diabetes, hypertension) that one must now learn how to manage on a daily basis. Stroke causes cognitive dysfunction, depression, and fatigue. A cyclical relationship emerges in which results of stroke impair the ability to live a healthy lifestyle, participate in activities, and prevent further stroke (Rochette, Desrosiers, Bravo, St-Cyr-Tribble, & Bourget, 2007).

An intervention used to manage chronic disease and break this cycle is self-management (SM) education. SM education is widely used to help people learn strategies to manage daily health care needs associated with their conditions and increase their self-efficacy (Schulman-Green et al., 2012). SM outcomes include increased involvement in social activities and activities of daily living (ADLs), reduced depression, improved quality of life (QOL), improved physical functioning, improved self-efficacy, and reduced health care utilization (Jones & Riazi, 2011). However, use of SM with those living with stroke has only begun to be explored (Wolf, Baum, Lee, & Hammel, 2016).

DESIGN: This study was a single-blind, exploratory, randomized controlled trial with participants with mild stroke. Participants were randomized to either the CDSMP intervention or an inactive control group. Inclusion criteria were as follows: (1) ischemic stroke with National Institutes of Health Stroke Scale total score of 0–5, (2) English speaking, (3) age ≥18 yr, and (4) at least one chronic condition. Exclusion criteria were (1) severe aphasia, (2) cognitive impairment (Montreal Cognitive Assessment score <21), (3) history of dementia, (4) other neurological diagnoses, (5) major psychiatric illness, (6) terminal illness, (7) score ≤20 on the Patient Health Questionnaire–9, and (9) age >90 yr.

METHOD: Participants completed baseline and 6-mo follow-up testing. Those randomized to intervention participated in a 2-hr/wk, 6-wk CDSMP program with two occupational therapist (OT) leaders and also completed posttesting. In CDSMP, learning takes place socially with peers with chronic conditions and through OTs’ modeling and resource sharing for three main tasks: medical management, role management, and emotional management. Our comprehensive assessment battery included 11 measures ranging from health status to QOL to activity participation.

RESULTS: Sixty-eight participants were randomized, with 18 completing intervention and 28 forming the control group. Wilcoxon signed-rank testing found a significant difference between those who received the CDSMP and those who did not in health care utilization, including visits to physicians (p < .001), visits to the emergency room (p < .005), times hospitalized (p < .001), and nights in the hospital (p < .001). There was, however, no difference between groups in perceived self-efficacy or self-perception of symptoms. There was a significant difference between groups in the physical health QOL domain of the WHOQOL–BREF, which includes ADLs and work capacity (p < .001).

CONCLUSION: Results demonstrate that there were some effects between groups, favoring the CDSMP group, in reducing health care use and in some aspects of QOL and participation. A unique difference seen in this population compared with previous studies is that there was no measureable effect on self-efficacy, which is seen as a primary outcome measure for the CDSMP. These results need to be confirmed in a future larger study.

References

Jones, F., & Riazi, A. (2011). Self-efficacy and self-management after stroke: A systematic review. Disability and Rehabilitation, 33, 797–810. https://doi.org/10.3109/09638288.2010.511415

Rochette, A., Desrosiers, J., Bravo, G., St-Cyr-Tribble, D., & Bourget, A. (2007). Changes in participation after a mild stroke: Quantitative and qualitative perspectives. Topics in Stroke Rehabilitation, 14(3), 59–68. https://doi.org/10.1310/tsr1403-59

Schulman-Green, D., Jaser, S., Martin, F., Alonzo, A., Grey, M., McCorkle, R., . . . Whittemore, R. (2012). Processes of self-management in chronic illness. Journal of Nursing Scholarship, 44, 136–144. https://doi.org/10.1111/j.1547-5069.2012.01444.x

Wolf, T. J., Baum, C., & Connor, L. T. (2009). Changing face of stroke: Implications for occupational therapy practice. American Journal of Occupational Therapy, 63, 621–625. https://doi.org/10.5014/ajot.63.5.621

Wolf, T. J., Baum, C. M., Lee, D., & Hammel, J. (2016). The development of the Improving Participation After Stroke Self-Management Program (IPASS): An exploratory randomized clinical study. Topics in Stroke Rehabilitation, 23, 284–292. https://doi.org/10.1080/10749357.2016.1155278