Multiple sclerosis (MS) and related disorders (Devic’s disease, or neuromyelitis optica; transverse myelitis) are a family of progressive, relapsing–remitting diseases that have a profound effect on patients’ ability to engage in everyday activities. More than 400,000 people with MS live in the United States, and approximately 200 Americans are diagnosed with MS each week (National Multiple Sclerosis Society, n.d.). MS is a systemic autoimmune disease in which a person’s body attacks the myelin sheath surrounding the brain and spinal cord neurons. The deterioration of the myelin sheath impedes the transmission of neural impulses fired throughout the body, disturbing fluidity of movement (Dirette, 2007). People diagnosed with MS grapple with many disabling effects in everyday activities, such as impaired functional mobility and difficulty performing self-care. Significant changes in physical and cognitive level of function often lead to hospitalizations and require the need for medical and rehabilitative services.

Occupational therapy is part of the rehabilitative team that focuses on helping people maximize their independence in daily activities. Interventions in occupational therapy for people with MS may include training in the use of adaptive equipment, range-of-motion exercises, splinting, cognitive rehabilitation, and energy conservation education to assist with fatigue management (Baker & Tickle-Degnen, 2001; Mathiowetz, Finlayson, Matuska, Chen, & Luo, 2005; Matuska, Mathiowetz, & Finlayson, 2007).

During relapses, patients with MS are often admitted to inpatient hospitals for rehabilitation to address issues impeding their function in day-to-day activities. Although substantial attention has been given to developing new medication and determining the etiology of the disease, far less attention has been given to rehabilitation services, especially inpatient rehabilitation services (Ciccone et al., 2008; Martinelli-Boneschi, Rovaris, Capra, & Comi, 2005; Rojas, Romano, Ciapponi, Patrucco, & Cristiano, 2009). According to research completed to date, inpatient rehabilitation services have a positive impact on people with MS (Freeman, Langdon, Hobart, & Thompson, 1997; Solari et al., 1999). Freeman et al. (1997)  concluded that multidisciplinary inpatient rehabilitation programs that include occupational therapy significantly reduced disability, as measured by the FIM™ (Uniform Data System for Medical Rehabilitation, 1997), and handicap, as measured by the London Handicap Scale (Harwood, Rogers, Dickinson, & Ebrahim, 1994). Similarly, a study by Solari et al. (1999)  found that inpatient rehabilitation can clinically and statistically reduce disability and improve quality of life for patients with MS, as evidenced by an increase in FIM scores and by an increase in the patients’ perceptions of their quality of life.

Despite these positive findings, few studies have been completed that specifically target the effectiveness of occupational therapy interventions with people with MS and related disorders. Occupational therapy focuses on aiding people to function to the best of their ability by addressing both physical and cognitive deficits; hence, it plays a vital role in the rehabilitation of patients with MS. However, the Cochrane review conducted by Steultjens et al. (2003)  found only three randomized, controlled efficacy studies that addressed occupational therapy interventions with patients with MS. Results of this review indicated that no conclusions could be drawn regarding whether occupational therapy improves outcomes in such patients. By contrast, a meta-analysis completed in 2001 suggested that occupational therapy has a strong, positive effect on people with MS (Baker & Tickle-Degnen, 2001). Other studies have demonstrated the effectiveness of specific occupational therapy interventions that focus on energy conservation techniques in patients with MS (Mathiowetz et al., 2005; Matuska et al., 2007). Finally, a study by Finlayson, Garcia, and Cho (2008)  revealed that 98% (n = 44) of patients with MS receiving occupational therapy services were satisfied or very satisfied with their treatment and thought that it was important or very important to their health and well-being. These inconsistent findings, along with the lack of evidence for specific occupational therapy interventions that are effective at targeting specific and positive outcomes for patients with MS, make it necessary to complete further research.

Our purpose in this study was to understand how different occupational therapy interventions enable patients to meet their individual goals by the time of discharge from an inpatient rehabilitation setting, as measured by the FIM. We addressed this issue by retrospectively examining the documented occupational therapy services of patients with MS and related disorders in an urban inpatient rehabilitation center during a 5-yr period. On the basis of the literature, we proposed that comprehensive inpatient occupational therapy services contributed significantly to the positive outcomes in FIM scores in patients with MS and related disorders.

This study involved a retrospective data analysis of past medical charts. The institutional review board at the Rush University Medical Center approved the study. No actual patients were enrolled in the study. We included client charts on the basis of these selection criteria: (1) diagnosed with MS or a related disorder, (2) stayed in the inpatient rehabilitation center, (3) recipient of occupational therapy services, (4) established initial goals with the occupational therapist, and (5) was reevaluated on goal status at discharge. We examined charts dated from August 2003 through August 2008. Access to client charts was provided to us through the Rush University Medical Center; in total, we examined 193 patient charts.

We developed two documents specifically for this project: (1) a data capture sheet and (2) a demographic information sheet. The data capture sheet included information such as specific occupational therapy interventions, duration of each intervention, functional performance at initial assessment, expected performance, and discharge performance. Occupational therapy interventions included were hot–cold packs, sensory integration, manual therapy, massage, contrast baths, orthotic fitting, cognitive skills, neuromuscular reeducation, community reintegration, self-care, occupation-based therapeutic activities, therapeutic exercises, evaluation, reevaluation, and group. We obtained study participants’ functional performance by extracting the patient’s initial assessment, goal, and discharge FIM scores.

The FIM is a standardized evaluation tool with high reliability and validity (Dodds, Martin, Stolov, & Deyo, 1993). FIM scores were recorded for feeding, grooming, bathing, upper-extremity dressing, lower-extremity dressing, toileting, toilet transfers, tub or shower transfers, comprehension, expression, social interaction, problem solving, and memory. One data capture sheet was completed for each patient’s hospital stay. We collected demographic information, without any patient-identifying information, on the demographic information sheet. No direct patient identifiers were collected.

All medical charts were retrieved from the Rush University Medical Center’s medical records office and returned to the office after data were extracted. Data collection sheets were kept in a secure, locked office at the hospital. Two lead occupational therapy clinicians from the Rush University Medical Center trained research students on proper protocol for data extraction from the medical charts. To ensure high interrater reliability, all study staff demonstrated 100% proficiency over five trials with the data capture sheet and demographic information sheet before they extracted data independently. The study clinicians and principal investigator ensured proper training of all staff so that all data would remain confidential and Health Insurance Portability and Accountability Act and personal health information requirements would not be violated.

Once the team had collected data from all 193 patient charts, study staff entered the information into the statistics database (SPSS–15; SPSS, Inc., Chicago). Data quality assurance included systematic training for research and clinical staff for data entry, interrater reliability monitoring, and electronic data verification. All data collected and entered into the database were entered by a primary rater and then verified by a secondary rater to ensure high reliability. Information missing from chart entries was identified in the process and verified for accuracy.

Initial data analysis included exploratory descriptive statistics. In the second series of analyses, we performed a series of correlation analyses to identify the relationship between treatment variables and functional outcomes. The treatment variables examined were occupational therapy intensity (number of occupational therapy treatment days/length of stay) and functional outcomes. In addition, we examined the relationship between the number of therapy minutes spent in each intervention and the change in FIM scores for each functional activity. Significant difference between discharge and initial FIM was examined by paired t test.

Descriptive statistics were used in examining patient charts. Patient demographic information is provided in Table 1. Multiple sclerosis accounted for 92.7% (n = 179) of the population, followed by related disorders (4.7%, n = 9). Most patients were female (76.7%; n = 148) and living at home before hospitalization (93.7%; n = 181). The mean length of stay was 13.34 days (SD = 6.31), and the patients received occupational therapy treatments on approximately 56% of the days that they were in the inpatient setting (Table 2). Most patients were discharged to home (79.8%; n = 154), and only 8.8% (n = 17) were transferred to a skilled nursing facility (Table 1). The most common occupational therapy interventions were self-care, therapeutic exercise, and occupation-based therapeutic activities (Table 2). In general, all patients showed improvement in their total FIM scores (Table 3). The greatest improvements were seen in ADLs (transfers, toileting, dressing, and bathing).

To assess the effectiveness of occupational therapy interventions in terms of improving functional independence in patients with MS, we conducted a Pearson’s correlation analysis (Table 4) between occupational therapy intensity (number of days treated/length of stay) and changes in FIM scores. We found that increasing occupational therapy intensity had a positive effect on FIM scores in all categories except feeding. However, the only significant correlations were in the categories of upper-extremity dressing (r = .15, p < .05) and memory (r = .20, p < .01).

The time spent on cognitive skills training correlated with improved independence in all categories of cognition (comprehension, expression, social interaction, problem solving, memory), and significant correlations were found in the categories of comprehension (r = .23, p < .01) and expression (r = .23, p < .01).

Training in self-care skills correlated positively with independence in all ADL categories except tub transfers and showed significant results in upper-extremity dressing (r = .24, p < .01), and toilet transfers (r = .15, p < .05). Patients who spent more time completing therapeutic activities demonstrated decreased independence in several areas of ADL performance, including significant negative correlations in the categories of lower-extremity dressing (r = −.17, p < .05) and tub transfers (r = −.21, p < .01). It appears that efficiency in self-care may be directly related to practicing self-care activities. The use of therapeutic exercises also showed mixed results on independence in ADLs, showing a positive impact on upper-extremity dressing (r = .21, p < .01) and a negative impact on tub transfers (r = −.18, p < .05; Table 5).

Occupational therapy is a part of the rehabilitation team that serves patients with MS during inpatient rehabilitation stays. The purpose of occupational therapy is to facilitate independence and participation in ADLs. Results from this study suggest that occupational therapists in an inpatient rehabilitation center were able to help achieve this purpose, because patients with MS who receive occupational therapy services in this setting demonstrated an increase in functional independence on discharge, as evidenced by improved mean FIM scores in all categories (Table 3). These findings are consistent with those reported by Baker and Tickle-Degnen (2001); Freeman et al. (1997); and Solari et al. (1999) . In the current study, the largest increases in functional independence were seen in the categories of tub transfers, toileting, toilet transfers, bathing, and upper-extremity dressing.

Results suggest little or no relationship between neuromuscular reeducation intervention, group therapy, and change in FIM score. Although it might be beneficial to use these types of interventions, results indicated no clear relationship between neuromuscular reeducation and group therapy on functional independence. Additionally, results indicate that the use of therapeutic activities and therapeutic exercise as interventions did not have a relationship to FIM scores. Because research results from this study did not provide clear evidence for these intervention approaches, our opinion is that more quantitative studies focusing on functional outcomes are necessary to show the effectiveness of neuromuscular reeducation, group therapy, therapeutic activities, and therapeutic exercises.

One can also conclude from these results that incorporating cognitive skills training into occupational therapy treatment of patients with MS will lead to improved cognition for these patients, especially in the areas of comprehension and expression. Cognitive retraining may be limited, however, because of Medicare and Medicaid reimbursement policies. Low reimbursement rates create an economic barrier because therapists are advised against treating the cognitive aspects of MS (Mendoza & Pittenger, 2003). Mendoza and Pittenger (2003)  further argued that patients with MS can greatly benefit from various cognitive rehabilitation interventions. The rehabilitation techniques allow people with memory disorders to develop the compensatory strategies that afford greater functional independence. Additionally, interventions in the areas of community reintegration and self-care skills would be recommended as part of the occupational therapy treatment plan because these resulted in improved independence in ADLs in this study. As mentioned earlier, the available literature has a dearth of quantitative research; therefore, these findings cannot be confirmed as prescriptive for the general population.

The study was performed at a single major urban medical rehabilitation center, and hence the sample does not reflect the entire population of patients with MS and related disorders. Future studies may consider including samples from several hospitals and incorporating patients residing in suburban and rural locations. Most patients in the study, approximately 76.7%, were female, and the results may not accurately represent typical treatment outcomes for male patients. Because of changes in the medical center’s documentation procedures, on occasion the total number of units of occupational therapy treatment was difficult to decipher. Units of treatment that were unclear in the documentation were recorded as one unit, respectively. Additionally, each therapist had a slightly different method of chart documentation. Also, it was difficult to differentiate between which activities constituted therapeutic activities and which constituted therapeutic exercises because no specific definitions existed. Because the study was retrospective, we had no control over variables and there was no way to verify the veracity of the data collected from the charts. Although our data show a positive increase in functional outcomes for patients with MS, those results may be the result of Type I error. Finally, the correlations used in this study do not provide evidence of cause and effect.

The results support the use of occupational therapy for clients with MS and MS-related disorders in an inpatient rehabilitation setting. All patients’ FIM scores increased, an outcome that is directly or indirectly related to the occupational therapy services provided. The current study supports the efforts of other researchers who have stated that occupational therapy along with other rehabilitation treatments are effective in improving the occupational performance of clients who had at least moderate levels of impairment (Baker & Tickle-Degnen, 2001).

This study also provides concrete evidence for specific treatments that were the most effective during patients’ stays in the rehabilitation center. This information in itself increases the scope of occupational therapy practice. Our findings can be used for future evidence-based research, including examining specific intervention protocols, examining occupational therapy intensity and effectiveness of care and, possibly, examining which comorbidities are linked to the length of stay during rehabilitation care. Evidence included in this article is limited to retrospective analysis of patient charts. A more in-depth analysis of the data, including a regression analysis, may be beneficial for future research, including a randomized controlled trial.

We sincerely thank the Rush University Medical Center Medical Records Department for its ready cooperation in obtaining the charts and the Rush University Medical Center for providing support and resources to complete the study. We also thank the Occupational Therapy Department for creating the opportunity for the study and gratefully acknowledge a pilot grant to Kinsuk Maitra from the College of Health Sciences.