Five-Year Retrospective Study of Inpatient Occupational Therapy Outcomes for Patients With Multiple Sclerosis

Background

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.

Method

Results

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).

Discussion

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.

Limitations

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.