ORIGINAL ARTICLE doi: 10.1111/j.1752-9824.2011.01125.x
A self-management program for veterans and spouses living with
Parkinson’s disease
Naomi Nelson PhD, RN
Co-Associate Director of Education, Parkinson’s Disease Research, Education & Clinical Center, Michael E. DeBakey Veteran
Affairs Medical Center, Houston, Texas, USA
Dorothy Wong PhD
Committee Member, Parkinson’s Disease Research, Education and Clinical Center, Michael E. DeBakey Veteran Affairs
Medical Center, Houston, Texas, USA
Eugene Lai MD, PhD
Director, Parkinson’s Disease Research, Education and Clinical Center, Michael E. DeBakey Veteran Affairs Medical Center,
Houston, Texas, USA
Submitted for publication: 28 July 2010
Accepted for publication: 18 December 2010
Correspondence:
Naomi Nelson
PADRECC 127PD, Michael E. DeBakey
Veteran Affairs Medical Center,
2002 Holcombe Blvd.
Houston, TX 77030
USA
Telephone: +1 713 523-6375
E-mail: [email protected]
Source of research funding:
Parkinson’s Disease Research, Education,
and Clinical Center (PADRECC),
Department of Veteran Affairs, USA.
NELSON NNELSON N, WONG D & LAI E (2011)WONG D & LAI E (2011) Journal of Nursing and Healthcare of
Chronic Illness 3, 496–503
A self-management program for veterans and spouses living with Parkinson’s
disease
Aims and objectives. The objective of this study was to determine whether Veterans
and their spouses would participate in a self-management educational programme
where they would practise the principles of self-efficacy for managing their chronic
illnesses. The programme was designed using the Chronic Disease Self-Management
Program of Stanford University in Palo Alto, California.
Background. Whereas programmes for self-management of chronic conditions
(arthritis, AIDS, diabetes) have been established for some time, only a few specific
programmes for Parkinson’s disease had been cited in the literature at the time of this
study. In this report,wedescribeour initial attemptsat recruitment, administrationand
evaluationof thisprogrammeforasmallgroupofparticipantswith thespecific intentof
assessing its feasibility and appropriateness for Veterans seen in an outpatient setting.
Conclusions. Our study revealed that participants were willing to commit to an
intensive interventionalprogramme,andwithin thegroupsettingwereable toapply the
principles of self-efficacy with guidance from their peers and facilitator. The support of
the group was a strong motivator for continued participation and the practice of self-
management skills. However, the progression of Parkinson’s disease and the lack of
long-term follow-up prevented the identification of measurable significant changes.
Relevance toclinicalpractice. Patients livingwithchronic illnessappear tobenefit from
groupeducationalprogrammes, and this format couldbeadapted forothers livingwith
neurodegenerative illnesses and other chronic conditions.
Key words: Parkinson’s disease, patients, self-management, veterans
496 � 2011 Blackwell Publishing Ltd
Introduction
Chronic disease extracts substantial burden on patients, their
families and health care resources. Researchers in the fields of
health care economics (Agarwal 2005, Linnell 2005), health
care policies (Committee on Quality of Life in America 2001)
and health care education (Lorig et al. 2007) encourage an
active partnership between patients and health care profes-
sionals wherein the patient assumes more knowledge and
responsibility for care, and the professional assumes the role
of a teacher who supports the patient in developing skilled
practices of self-management. With Parkinson’s disease (PD),
even when the course of the disease is addressed with optimal
medical and surgical therapies, patients have progressive
disability and endure a difficult array of disease sequelae.
Although there is some disability that is an inescapably part
of the disease process, psychological and physical challenges
also exist that might be reduced with short-term appropriate
exercise interventions and/or lifestyle modifications (Hou &
Lai 2008). The management of lifestyle health habits,
medication administration, exercise regimens, stress manage-
ment and communication strategies may be particularly
challenging for patients who have PD (Nelson 2008). Chronic
Disease Self-Management workshops may provide the most
beneficial format for learning disease-specific self-manage-
ment skills (Sawyer 2007).
Background
The theoretical foundation of this self-management pro-
gramme is rooted in Bandura’s social cognitive theory
(Bandura 1986). The cornerstone of social cognitive theory
is self-efficacy (SE) or the belief that self-reflective thought
affects one’s behaviour. More simply stated, how one believes
essentially predicts the outcomes. Perceived SE is resilient and
can predict change in different areas that are essential to
managing chronic illness such as social and coping skills,
depression and health behaviours. Social modelling, or
learning from the behaviour and problem-solving of others,
is another important construct of this theory and an integral
component of the Chronic Disease Self-Management Pro-
gram (CDSMP) (Bandura 1997).
The CDSMP is a community-based intervention workshop,
developed by Dr. Kate Lorig at the Stanford Patient Educa-
tion Research Center (SPERC) in Palo Alto, California, USA,
and based on social-efficacy theory (Lorig et al. 1999a). In
Lorig’s structured programme, learning is facilitated in five
core areas – problem-solving, decision-making, resource
utilisation, patient–provider partnerships and action plans.
The formulation of action plans (something the participant
‘wants to do’) is the core strategy by which behavioural
changes are promoted (Lorig et al. 2001, Lorig 2003). After
the action plans are developed, a confidence level is estab-
lished by the participant which helps to determine the
likelihood that the action plan will be completed. In
subsequent weekly group sessions, the action plans are
reviewed, modified and discussed in the group with the
expectation that belief in one’s mastery of new skills will also
promote changes in the behaviour for other health habits.
(Lorig et al. 1999a, Lorig & Holman 2003). Training for this
programme involves a one-week didactic and experience-
based workshop session taught by Dr. Lorig and her
colleagues.
Programmes for self-management of chronic conditions
(arthritis, AIDS, diabetes) have been established for some
time (Lorig & Holman 1989, 1993, Lorig et al. 1998, 2007,
2009), but only a few programmes specifically for PD had
been reported in the literature at the time of this study (Fujii
et al. 1997, Lindskov et al. 2007, Montgomery et al. 1994)
none of which involved the Veteran population. In this
report, we describe our initial attempts at recruitment,
administration and evaluation of this programme for a small
group of participants with the specific intent of assessing its
feasibility and appropriateness for Veterans living with a
chronic illness.
Methods
Twenty participants, including 13 patients with PD and seven
of their spouses, were recruited for this study from the
Parkinson’s Disease Research, Education, and Clinical Center
(PADRECC) at the Michael E. DeBakey Veterans Affairs
Medical Center (MEDVAMC) in Houston, Texas, USA.
Eight potential participants declined to participate citing the
high cost of gasoline, distance from the VA, and difficulty to
commit to the programme for the whole duration.
Patients were included in the study if they had been
diagnosed with PD by a movement disorders specialist and
had mild to moderate disease as measured by the Hoehn &
Yahr Staging (H&Y) of 2Æ0–3Æ0 (Hoehn & Yahr 1967). At
baseline, we also measured the participants’ functional
capabilities by the Schwab and England Activities of Daily
Living Scale (S&E) that is considered a disability measure and
is influenced by comorbid conditions, the patient’s mental
state and the effect of medications (Schwab & England
1960). Screening criteria also included scores on the mini–
mental status examination (MMSE > 24) (Folstein et al.
1975) and a depression score <12 as measured by the
20-item Center for Epidemiologic Studies Depression Scale
(CES-D) (Radloff 1977). All 13 Veterans who were screened
Original article Self-management
� 2011 Blackwell Publishing Ltd 497
with these measures qualified to enroll in the study. Similarly,
all spouses met the criteria for enrolment admission, which
included the absence of dementia and depression and the
presence of at least one chronic medical condition.
The primary purpose of the workshop was to determine the
feasibility of recruitment, retention, appropriateness of mea-
sures and the usefulness of CDSMP for this group of Veterans
and their spouses. We conducted a pretest–post-test pilot
study entitled ‘Self-Management Training for Veterans with
PD and their Spouses’ that involved six weekly workshops
based on the Stanford University Chronic Disease Self-
Management Program. Testing was conducted at baseline,
six weeks later, and six months following the completion of
the intervention. The PD-specific measures were not admin-
istered to the spouses. Each session lasted 1½–2 hours and
was facilitated by two psychologists who were educated and
certified as Master Trainers in the CDSMP at Stanford
University. For almost twenty years, one of the co-facilitators
had lived with PD; this situation met the CDSMP require-
ment of at least one facilitator presently living with a chronic
illness (Lorig et al. 1999b).
The task of ‘taking action’ or developing a weekly action
plan (a contract) was one of the most important compo-
nents of the CDSMP. Each week, participants identified
what they wished to accomplish in the following week,
developed reasonable and behaviour-specific action steps
and monitored their confidence for successfully implement-
ing the plan.
Permission to conduct this research project was approved
by the Baylor College of Medicine Institutional Review Board
and the MEDVAMC Research and Development Committee.
Demographics
Participants completed questionnaires at baseline with the
following information being assessed: sex, age, education,
ethnicity, marital status and Veteran status.
Quality of life
The primary outcome measure for determining the Veteran’s
quality of life was an eight-item instrument – The Short Form
Parkinson’s Disease Questionnaire (PDQ-8). This is derived
from the original 39 items of the Parkinson Questionnaire
(PDQ-39), which was tested on 359 persons with PD
(Jenkinson et al. 1997). The content and construct validity
of the PDQ-39 and PDQ-8 scores have been well established,
and in the original studies, the mean PDQ-8 index score was
47Æ25 and the mean PDQ-39 index score was 44Æ7. A higher
score on both instruments indicates a less favourable quality
of life. We chose to use the PDQ-8 because of our preference
for an overall index and its high correlation and strong
statistical properties with the PDQ-39 and the Hoehn and
Yahr Scale (Jenkinson et al. 1997).
Self-efficacy
For the outcome measure of self-efficacy, we used the six-item
scale recommended by the Stanford Patient Education
Research Center (SPERC) that assesses confidence in manag-
ing disease in general (Lorig et al. 1996). The Likert response
scale is 0–10 with a higher score indicating greater self-
confidence in managing illness. This scale was developed
from several scales of self-efficacy and was originally tested
on 605 participants with chronic illness (mean score of 5Æ17
and internal consistency 0Æ91) (Lorig et al. 1996).
Depression
To measure depression, we chose the 20-item Center for
Epidemiologic Studies Depression Scale (CES-D). The CES-D
measures self-reported dimensions of depression experienced
in the past week with a higher score indicating more
depression (Radloff 1977). The CDSMP previously used the
20-item scale and tested it on 237 chronically ill individuals
with a mean score of 16Æ72 (Lorig et al. 2001, Radloff 1977).
The CES-D has been shown to be an appropriate instrument
for the older people as physical disability does not signifi-
cantly affect its validity (Lorig et al. 1996).
Fatigue and pain
We used the one-item SPERC visual numeric scales to
measure pain and fatigue, with a higher number indicating
more severity. These scales are modified versions of the visual
analogue scales, which are suggested as health approxima-
tions and preferences for health states (Lorig et al. 1996). The
degree of pain was originally tested on 237 persons with pain
(mean score 4Æ50), and fatigue was tested on 122 persons
with a mean score 4Æ89 (Lorig et al. 1996).
Exercise
The SPERC exercise behaviour scale is a six-item Likert
instrument that records the weekly amount of time spent on
stretching/strengthening and aerobic exercise (<30 minutes/
week to more than 3 hours/week). The SPERC tested this
instrument on 1130 participants with mean scores of 40Æ1 for
stretching and 90Æ6 minutes for aerobic exercise (Lorig et al.
1996).
N Nelson et al.
498 � 2011 Blackwell Publishing Ltd
Self-rated health status
We also measured the participants’ self-rated health by a five-
point scale ranging from 1 (excellent) to 5 (poor). This scale
was used in the National Health Interview Survey and tested
on 1129 participants with a mean score of 3Æ29 and test–
retest reliability of 0Æ92 (Lorig et al. 1996, 1999b). The lower
number indicates better health with the severity of illness
increasing with a higher number.
The Statistical Package for the Social Sciences (SPSSSPSS),
version 16, was used for analysis in this study (Field 2009).
Descriptive statistics were used to describe measures of
central tendency. Repeated measures for non-parametric data
were analysed using Friedman’s analysis of variance. All
participants served as their own controls. The investigators
generated a brief survey for the participants’ evaluation of the
programme.
Results
Thirteen male Veterans with PD and seven of their spouses
were enrolled and completed the screening instruments
(n = 20). One Veteran dropped out after the first session
stating that he became discouraged after observing a more
rapid progression of PD in a younger patient. The mean age
was 73Æ8 years (Veterans) and 73Æ4 years (spouses). Eighty-
five per cent (n = 17) were White-American, and 15% (n = 3)
were Hispanic-American. Eighty-five per cent had attended
some college. Twelve Veterans were married, and one was
widowed. One Veteran and two spouses were referred for
professional follow-up based on their self-reported depres-
sion scores. Patient and spouse characteristics are presented
in Table 1.
For the Veterans, the severity of their PD was considered
mild to moderate as measured by the Hoehn & Yahr Scale
(range of 2Æ0–3Æ5) and the Schwab and England Activities of
Daily Living Scale (range 70–90%) (Hoehn & Yahr 1967,
Schwab & England 1960). The spouses were a relatively
healthy group scoring 100% on the S&E. Both groups
obtained MMSE scores >24. The frequency of self-reported
comorbid conditions included heart disease, hypertension
and hypercholesteremia (n = 10), arthritis (n = 4), cancer in
remission (n = 1), pulmonary problems (n = 2) and other
(n = 2). Diabetes was not reported by any of the participants.
The participants’ health conditions are presented in Table 1.
Outcome measures for both Veterans and spouses are listed
in Table 2 for the three testing periods. Statistics for all
variables are based on measures without missing data. Only
the fatigue variable indicated significant changes – a wors-
ening of fatigue – over time (3Æ5, 4Æ5, 4Æ6; p = 0Æ05). The
comparison results for most variables (mean scores) were
non-significant with trends at six weeks for an improved
quality of life (30Æ97, 24Æ14, 27Æ70; p = ns), increased self-
efficacy (6Æ91, 7Æ57, 6Æ33; p = ns) and less pain (3Æ69, 2Æ93,
3Æ65; p = ns). However, at the six-month post-intervention,
these variables had not shown continued improvement.
Depression increased slightly over time, and at six months,
participants did report a slight increase in the amount of time
they exercised. Self-reported health status remained essen-
tially the same throughout the study.
We considered the evaluation comments from the partic-
ipants to be equally important for our project. For example,
more than 60% of the subjects were satisfied with the
workshop format, organisation, environment, skills and
learning. Fewer, <50%, were greatly or completely satisfied
with the topics of the workshop. Several open-ended
responses also indicated the desire of the patients for
additional learning through homework and specific discus-
sions about PD. Figure 1 and Table 3 describe these findings.
The data were also analysed separately for the participants
(correlations and repeated measures), but these results are not
Table 1 Demographics and illness characteristics of veterans and
spouses (n = 20)
Variables Veterans Spouses
Gender, n (%)
Men 13 (65)
Women 7 (35)
Age, mean (range) 73Æ8 years
(59–85)
73Æ4 years
(61–84)
Ethnic background, n (%)
Anglo-Am. 11 (85) 6 (86)
Hispanic-Am. 2 (15) 1 (14)
Education, n (%)
Some college 11 (85) 6 (86)
Married, n (%) 12 (92) 7 (100)
Parkinson’s disease, n (%) 13 (100) 0
Severity of Parkinson’s disease
Hoehn & Yahr Score
Mean (range)
2Æ5 (2Æ0–3Æ5)
NA
Cognitive status
Mini–mental status examination
Mean (range)
28Æ77 (25–30) 29Æ71 (29–30)
Activities of daily living
Schwab and England
Mean (range)
85 (70–90)
100
Other medical conditions, n
Arthritis 2 2
Cancer 1 0
Hypertension 1 2
Pulmonary problems 2 0
Coronary heart disease 1 1
Hypercholesterolemia 2 1
Other 0 2
Original article Self-management
� 2011 Blackwell Publishing Ltd 499
included owing to the small number of Veterans (n = 11) and
spouses (n = 4) who had completed each outcome measure in
its totality and the random nature of their non-responses.
Discussion
Our findings present evidence that a selected group of Veterans
with PD and their spouses were committed to an educational
programme that assisted them in learning healthy behaviours
in managing their chronic conditions. This type of study was
not intended to be a measurement study, and the possibility of
statistical errors exists with such a small, non-randomised
sample size. The numbers of the three sequential assessments
are presented so that some trends may be considered. For
example, the participants showed slightly more improvement
on the measures after six weeks than after six months –
especially for QOL, self-efficacy and pain. (See Table 2). These
three factors along with the fatigue variable worsened from
six weeks to six months. Although the amount of time spent on
exercise increased slightly from six weeks to six months, it
averaged less than 30 minutes a week for all three points in
time. These trends may suggest that the CDSMP group
workshop had a positive effect on the participants initially,
but that over time, the changes were less observable. Several
possible explanations for these findings are discussed below.
We chose to pattern our programme closely to the goals,
methods and assessment measures recommended by the
CDSMP, and this structure generally worked well in achieving
our initial recruitment objectives. As the workshop advanced
and we became more familiar with the course and our
participants, we recognised the needs for more content
flexibility regarding PD information and greater attention
to the physical and emotional impact of disease progression.
Consequently, with the identification and assessment of other
Table 2 Outcome measures for veterans and spouses
Variables Mean Pre-test Mean six-weeks Post-test Mean six-months Post-test
PDQ-8 (n = 11) (observed range = 2Æ5–56Æ25) 30Æ97 24Æ14 27Æ70*
Depression (n = 12) (observed range = 1–21) 8Æ17 8Æ58 9Æ58*
Self-efficacy (n = 12) (observed range) 6Æ91 7Æ57 6Æ33*
Pain (n = 10) (observed range = 1–10) 3Æ60 3Æ00 3Æ60*
Health Status (n = 15) (observed range = 1–4) 2Æ63 2Æ89 2Æ50*
Fatigue (n = 10) (observed range = 1–8) 3Æ50 4Æ50 4Æ60**
Exercise (n = 12) (observed range = 0–30 minutes/weeks) <30 minutes/weeks <30 minutes/weeks <30 minutes/weeks*
*p = ns, **p = 0Æ05.
Table 3 Selected evaluation comments
In the words of the participants…The pace was perfect.
I’d spell out more homework next time, i.e. assign pages of the
book to read.
The atmosphere was very professional, informative, and pleasant.
I would give it an A+.
Allow a block of time each session to discuss a specific area of
concern about Parkinson’s disease for both caregivers and
patients.
Many thanks for the opportunity. I’ll miss the group.
I hope our group meets together again in the future.
The exercise program was excellent – especially how to get up after
falling.
6 7 7 613
7 7
47
27 27 29
7
50
13
47
6066 64
80
43
87
0
10
20
30
40
50
60
70
80
90
100
Sa sfac onwith topic
Sa sfac onwith format
Sa sfac onwith
organisa on
Sa sfac onwith
environment
Sa sfac onwith facilitators'
skills
Sa sfac onwith learning
Recommendworkshop to
veteran
Perc
enta
ge
Degree of sa sfac on
Evalua on by par cipants, n = 15
Slightly Moderately Greatly Completely
Figure 1 Chronic Disease Self-Management
Program evaluation by participants.
N Nelson et al.
500 � 2011 Blackwell Publishing Ltd
outcomes, specific health changes over time may have been
more observable. For example, a pre- and postassessment of
the impact of the Veterans’ comorbidities, feelings of control
and connectedness, the degree of disease distress, baseline
knowledge about PD and personal expectations for the
course may have strengthened our study and provided
additional outcomes that may have mediated the results.
Studies cited below present evidence that a traditional self-
management programme may benefit from consideration and
inclusion of these factors and others.
In addressing the complexity of chronic illness and the
impact of multimorbidities on self-management among the
older people, Bayliss et al. (2007) identified several significant
deterrents to self-management and quality of life outcomes.
These barriers included the overwhelming nature of multi-
morbidities, reduced social activity, greater financial difficul-
ties and the resulting impact on depressive symptoms and
disease burden.
Additionally, several provocative research studies discuss
the limitations of self-management and other patient educa-
tion programmes (Wagner et al. 1999, Weingarten et al.
2002, Elzen et al. 2007, Nolte et al. 2007, Osborne et al.
2007, Barlow et al. 2009). One study suggests using more
sensitive and operational measurements and introduces the
Health Education Impact Questionnaire (heiQ) as one
instrument designed to measure the outcomes of health
education courses (Osborne et al. 2007). Other researchers
suggest the use of more than one intervention (Weingarten
et al. 2002) and more flexibility (Jordan & Osborne 2007) in
the patient education courses. Additional outcome consider-
ations include the measurement of psychological support and
well-being, perceptions of control, social isolation and health
knowledge (Barlow et al. 2000, 2009).
Significant changes in the health behaviours and QOL of
patients with PD and spouses may be less observable over a
six-month period of time when compared with patients living
with other more stable chronic conditions. As PD is a
fluctuating, degenerative condition, assessment measures may
reflect the experience of worsening symptoms on the days of
testing that could influence the results. For example, if the
six-month assessments occurred during a physical decline in
health, the scores on the outcome measures may reflect the
abrupt, unpredictable nature of change in PD more than the
effects of the educational programme. A remark by one of
the facilitators who has lived with PD for over twenty years
best explains this trajectory: ‘Acceptance of the disease is very
important. With each unpredictable gradual and abrupt
decline, you are learning to live with a different disease.
Precipitous drops in functioning resulting in increased
dependency and loss are not uncommon.’
The participants expressed strong support and enthusiasm
for the group cohesiveness that formed during the workshop
and that eagerness continued throughout the duration of the
programme. In the workshop, participants effectively used
self-management principles, but on their own and with less
direction, their eagerness to learn and to monitor health
behaviours became more difficult. We believe that the
CDSMP educational programme may have been strengthened
by a longer duration of the workshop subsequently followed
by strategic scheduling of telephone calls or clinic visits. Pre-
and poststudy interviews with the participants would also
have provided an opportunity for them to compare their
preworkshop expectations with their completed goals. Sub-
sequent longer-term follow-up was difficult because four
Veterans in the group died within two years after completion
and one subject moved out of state.
The fact that the attrition rate for completion of the study
was low and that the participants wanted the course to be
continued enhances the appropriateness of this self-manage-
ment educational programme that provides group support
and cohesiveness. By enrolling spouses in this programme,
many of the Veterans were encouraged to attend each session
and received additional support for their goal attainment
outside of the group workshop. It is perhaps not surprising
that the results from some of the variables (quality of life,
depression and pain) showed an improvement after the six-
week course only to drop again after six months. This lends
support to the belief that the group goal-setting and
accountability had an influence on participants’ perceptions
of their chronic conditions.
Conclusion
In conclusion, the study demonstrated the ability to actively
recruit and retain Veterans and their spouses who were
committed to a research-based educational programme that
involved a considerable time commitment. Participants were
genuinely pleased with the CDSMP as evidenced by their
subjective evaluation (See Fig. 1 and Table 3). Even though
their comments differed substantially from the test scores, the
core format and organisation of the CDSMP were valued by
the participants. Almost 90% of the evaluation respondents
were greatly satisfied with what they had learnt, and 96%
would recommend the workshop to another Veteran.
We learnt from this study that the use of self-efficacy as
a construct in formulating self-management skills is
worthwhile in learning to live with chronic illness (Marks
et al. 2005). We also learnt that the progression of neurode-
generative diseases is different from the trajectory of many
other chronic illnesses such as diabetes and arthritis and that
Original article Self-management
� 2011 Blackwell Publishing Ltd 501
the measurements of change may need to be adapted for
greater sensitivity of individual decline. Although the self-
reported measures of our study indicated little change, we
cannot assume that true changes in health behaviours did not
occur. For example, because the quantitative measures did
not detect noticeable change, qualitative methods may have
added another dimension in assessing adjustment, self-
efficacy, problem-solving and goal-setting and other health
behaviours. Additionally, these older, less active Veterans
were experiencing a relatively stable course of their illness
and that obvious and immediate changes in managing their
health were difficult to quantify. To improve the efficacy of
future studies for Veterans with PD, we also recommend a
larger randomised sample of participants, a control group
and more robust measurements for self-management.
Relevance to clinical practice
This pilot study supports the belief that the degenerative
aspect of PD makes the education and management of this
disease somewhat different from dealing with a more stable
chronic illness.
Living with chronic illness is complex, and the use of self-
management skills, when learnt through CDSMP, has been
shown to be efficacious (Marks et al. 2005). However, the
CDSMP programme alone may not be sufficient for those living
with the degenerative nature of PD. Future studies that focus on
PD and other progressive neurological conditions such as
multiple sclerosis may call for a more flexible, adapted version
of the CDSMP. A specific PD educational programme could
conceivably incorporate CDSMP skills training plus funda-
mental knowledge about all stages of the disease process
incorporating medical treatment (Hou & Lai 2008), speech
and rehabilitation therapies (Fox et al. 2008, Trail 2006), the
implications of activation for goal-setting (Hibbard et al.
2007) and practical application of psychological tools that
assist in the emotional adaptation to the illness (Suzukamo
et al. 2006). More opportunities for observing reactions to
physical changes and ways of coping with disease-related stress
could be integrated into the group format without difficulty.
Contribution
Study design: NN, DW, EL; data analysis: NN, DW, EL and
manuscript preparation: NN, DW, EL.
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Original article Self-management
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