Structured Abstract
Multiple Sclerosis Structured Abstract - MS #11
Comprehensive outpatient rehabilitation to improve quality of life for persons with progressive multiple sclerosis
CITATION: Di Fabio, R. P., Soderberg, J., Choi, T., Hansen, C. R., & Schapiro, R. T. (1998). Extended outpatient rehabilitation: Its influence on symptom frequency, fatigue, and functional status for persons with progressive multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 79, 141-146.
LEVEL OF EVIDENCE: IIA3a
RESEARCH OBJECTIVE/QUESTION
"To evaluate the effectiveness of an extended outpatient rehabilitation program for highly involved patients with a chronic progressive form of MS" (p. 142).
DESIGN
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RCT |
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Single Case |
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Case Control |
|
x |
Cohort |
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Before-After |
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Cross Sectional |
First 20 patients were placed in a treatment group. 29 clients who were admitted to the center during the course of study were placed on a late-entry list and their data were not used in the study. The remaining 26 were wait listed for the full year of the treatment. All participants received baseline evaluation at the beginning of the year and were reevaluated after 1 year of treatment.
SAMPLING PROCEDURE
Consecutive sampling of all MS patients who met the criteria and were referred for treatment.
SAMPLE
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N = 46 |
Mean age = 49.5 |
Male = 12 |
Female = 34 |
MS clients with a score of 5 to 8 on the Kurtzke Expanded Disability Status (severe disability); sampled consecutively from the center's waiting list. Patients were generally older (mean age 50) and had had MS for more than 15 years. Around 50% receive home health care. No significant differences between treatment (n = 20) and controls (n = 26) for characteristics.
OUTCOMES
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Life roles |
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Tasks |
x |
Activities |
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Abilities/habits |
x |
Capacities |
OUTCOME AREAS
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Outcome Area |
Measures |
Reliability |
Validity |
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MS signs and symptoms |
MS-Related Symptom Checklist |
Test-retest - .8 - .89 Cronbach - .87 - .89 |
Goodness of fit with ADL self-care scale - .91 |
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Fatigue |
MS-Related Symptom Checklist (1 question) |
NR |
NR |
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Functional Status (bed mobility, wheelchair propulsion, bed transfers, ambulation, skin status) |
Rehabilitation Institute of Chicago Functional Assessment Scale (RIC-FAS) |
Interrater reliability - .83 - .98 |
NR |
NR=Not Reported
INTERVENTION
Description
Support services (support groups, social work, therapeutic rec, wound and fall prevention, seating and positioning, nutritional education)
Physical therapy (balance training, coordination, gait, transfer, endurance training, and ROM)
Occupational therapy (maintain the use of upper extremities for ADL and communication skills and attention span)
Who delivered
Support Services - Not stated
Physical Therapy - PT
Occupational Therapy - OT
Setting
Clinic
Frequency
Once a week, 5-hour therapy time
Duration
1 year
RESULTS
- Multiple regression used to compare 1 year MS Signs and Symptoms frequency score with group membership, demographic variables (e.g., age, gender, etc.), baseline RIC-FAS, and baseline MS Signs and Symptoms. Significant relationships between symptom frequency and group membership (R2 = .26, p = .02), symptom frequency and baseline RIC-FAS (R2 = .26, p = .02) and symptom frequency and baseline MS Symptom score (R2 = .38, p = .01).
- ANCOVA suggested that there were significant differences in fatigue levels between the treatment and control groups (F(1,30) = 9.68, p = .004) but no significant differences in functional level.
- Effect Sizes:
Symptom frequency: treatment group = .27, control group = -.32.
Fatigue: treatment group = .46, control group = -.20
Loss of functional status: treatment group = -.07, control group = -.70.
CONCLUSIONS
Biases - attention, masking, recall, contamination, different therapists, sample size, dropouts
Extended outpatient rehabilitation programs were beneficial for reducing fatigue and symptoms of MS. They also appeared to slow the rate of functional decline. This finding suggests that OTs working with clients with MS should consider placing them in a comprehensive and long-term rehabilitation program aimed at teaching coping and maintaining all skills.
Limitations
- Not clear what specific treatments were because they were based on need.
- Nonrandom assignment - Analysis of the participants at baseline, however, found no significant differences between the two.
- Those receiving treatment had more attention paid to them.
- Outcomes based on self-report may have been inaccurate. However, researchers stated that objective measures tended to cross validate with self-reports.
- Evaluators aware of group status of participants and purpose of study.
- Wait list group may have received treatments that influenced their outcomes.
- Sample size considered small for the number of variables examined.
- 35% of treatment group (n = 7) and 23% of control (n = 6) dropped out. Several died, moved, had illness, or transportation difficulties. 12% just dropped out (all in control group). Analysis of baseline score found no significant difference between those who remained and those who dropped out.
COMMENTARY
OT as part of a comprehensive long-term program appears to improve quality of life of MS patients.
Terminology used in this document is based on two systems of classification current at the time the evidence-based literature reviews were completed: Uniform Terminology for Occupational Therapy Practice-Third Edition (AOTA, 1994) and International Classification of Functioning, Disability and Health (ICIDH-2) (World Health Organization [WHO], 1999). More recently, the Uniform Terminology document was replaced by Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002), and modifications to ICIDH-2 were finalized in the International Classification of Functioning, Disability and Health (WHO, 2001).
This work is based on the evidence-based literature review completed by Nancy Baker, ScD, OTR, and Linda Tickle-Degnen, PhD, OTR/L, FAOTA.
For more information about the Evidence-Based Literature Review Project, contact the Practice Department at the American Occupational Therapy Association, 301-652-6611, x 2040.
Copyright 2003 American Occupational Therapy Association, Inc. All rights reserved. This material may be reproduced and distributed without prior written consent.
