Interventions for Instrumental Activities of Daily Living in Adults With Multiple Sclerosis

Occupational Therapy Assessment

Diego used the Occupational Profile (American Occupational Therapy Association [AOTA], 2021) to learn more about Kate’s occupational history, current patterns of daily life, contexts, and needs. The Occupational Profile revealed the following:

Kate’s foremost personal value is family (including her pets).

To gain additional clinical information, Diego then administered the Canadian Occupational Performance Measure (COPM; Law et al., 2019) to measure Kate’s perceived occupational performance and satisfaction in different areas of functioning. Higher scores (on a scale ranging from 1 to 10) indicate greater self-rated performance or satisfaction with occupations that Kate identified as important. He also administered the Godin Leisure Time Exercise Questionnaire (GLTEQ; Godin & Shephard, 1985) to determine a baseline for her PA levels. The GLTEQ summary score ranges from 0 to 119 points, and higher scores indicate more participation in physical activity. Assessment findings are summarized in Table 1.

Treatment Goals and Interventions

On the basis of the evaluation, Kate and Diego collaborated to establish occupational therapy intervention goals. They decided to prioritize managing Kate’s symptoms and discussed how important medication management and PA were to performance and participation in other valued daily life activities, such as home management and community participation (e.g., attending her sons’ after-school activities). Kate’s occupational therapy goals focused on integrating PA into her daily routine and improving her medication self-management. Both of these goals address health management occupations, which are defined by AOTA’s (2020) Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4) as “activities related to developing, managing, and maintaining health and wellness routines, including self-management, with the goal of improving or maintaining health to support participation in other occupations” (p. 32).

Application of Evidence

Diego reviewed evidence from the American Journal of Occupational Therapy (see Cunningham & Uyeshiro Simon, 2022) and integrated it into the intervention plan. This evidence was as follows:

strong strength of evidence for the use of coaching interventions (i.e., educational content, telephone-based coaching) to improve self-reported PA health management and maintenance routines (Dlugonski et al., 2012; Motl et al., 2017; Pilutti et al., 2014; Sandroff et al., 2014; Suh et al., 2015; Turner et al., 2016)

Given that most intervention themes in the systematic review (Cunningham & Uyeshiro Simon, 2022) had moderate to low strength of evidence, Diego also reviewed other important resources that could help inform his treatment decisions. He reviewed the OTPF–4, which outlined health management occupations and occupational therapy’s role in habit and routine formation or modification for overall health and wellness. He also reviewed the NMSS’s guidance on DMTs (NMSS, 2021a), PA recommendations (NMSS, 2021b), and strategies to manage heat sensitivity (NMSS, 2021c). Considering all available evidence, his own clinical expertise, and Kate’s established goals, Diego created an intervention plan. Clinical outcome measures included the GLTEQ for self-reported PA and the COPM for progress toward reinitiating a DMT.

Intervention 1: Coaching and Prescribed Exercise for Physical Activity Health Management Routines

One of Kate’s goals was to increase her PA routines to improve her fatigue levels, as recommended by her physician. However, Kate did not have any past experiences with PA or establishing PA health management routines. Although Cunningham and Uyeshiro Simon (2022) found strong strength of evidence for the use of coaching interventions to increase self-reported PA, Kate’s general lack of experience, occasional weakness, and lack of confidence in independently choosing and engaging in PA at the beginning of treatment made her request more support and supervision as she created new PA routines. As a result, Diego chose to use coaching with prescribed supervised exercise at least until Kate was comfortable performing PA routines more independently.

Diego’s intervention plan was based on Carter et al.’s (2014) study, which used the transtheoretical model (Prochaska & DiClemente, 1983) as a guiding framework for cognitive–behavioral techniques to facilitate long-term behavior change. Table 2 provides the frequency of clinic-based (i.e., supervised exercise plus coaching) and independent home- or community-based PA. During the first clinic-based visits, Diego trained Kate in PA safety and goal setting and helped her safely perform novel aerobic and resistance exercises. During subsequent visits, he advanced the intensity and duration of her PA routine, provided education on the benefits of PA and potential risks of a sedentary lifestyle, problem solved how to manage barriers to PA (e.g., heat sensitivity, time management), and discussed ways to find social support. He also collaborated with Kate to identify types of PA that matched her comfort level, existing routines, interests, and therapeutic goals, which included

light walking around the block when talking on the phone,

When completing her home-based PA, Kate at first mostly chose to copy the clinic-based exercises. In the third week of the intervention, though, a friend invited her for a walk, which she was able to successfully complete and found to be much more enjoyable. As a result, she continued to use walking in her community with her friend as her primary source of exercise outside of the clinic.

Toward the end of the intervention, Diego gradually reduced the amount of exercise completed in the clinic and began educating Kate on how to independently grade and improve her PA routines for long-term sustainability. She reported feeling more confident in her ability to explore different types of PA, incorporate PA into her daily routines, and safely grade her PA independently.

Intervention 2: Motivational Interviewing and Cognitive–Behavioral Therapy for Medication Health Management

Kate’s second goal was to improve her performance with medication management. The systematic review (Cunningham & Uyeshiro Simon, 2022) found moderate strength of evidence for individual coaching interventions to support medication management for people with MS, and Diego thought Bruce et al.’s (2016) study particularly matched Kate’s situation because she had already stopped her DMT injections and, at the time of evaluation, did not plan to reinitiate them. Although the Bruce et al. intervention was originally delivered through telehealth, Diego decided to incorporate this intervention into the first 5 to 6 wk of Kate’s clinic-based visits for development of an exercise and PA routine. This allowed him to build more rapport while addressing multiple goals within the same session, sometimes putting time aside for discussion and sometimes discussing medication management while Kate was exercising (e.g., walking on the treadmill).

Diego had a baseline understanding of MI philosophy (Miller & Rollnick, 2013) through his occupational therapy education. He reviewed the general principles of the MI approach (e.g., acceptance, support for patient autonomy, exploration of ambivalence) and watched a few video examples of MI to prepare for his sessions with Kate. He planned to use MI to aid Kate in examining the pros and cons of reinitiating DMT to allow her to come to her own best decision. If she stated an interest in reinitiating DMT, he planned to use MI-informed CBT to help her set goals, problem-solve barriers and supports, manage side effects, effectively communicate with her neurologist, and prevent another relapse in DMT adherence.

Kate was initially hesitant about reinitiating her DMT, but after analyzing the dissonance between her main goal (i.e., to live a long and healthy life) and her current behaviors (i.e., not adhering to her DMT), and obtaining more information from her neurologist, she was receptive to the idea of reinitiation. Toward the end of the intervention, Kate and Diego collaborated to create a plan for reinitiation that included strategies such as

performing DMT injections in the late evening, after the kids were asleep and when her partner could provide support and accountability;

During the 10th week of the PA intervention, Kate reported that she had scheduled an appointment with her neurologist to start the process of reinitiating her DMT. Table 3 shows Kate’s clinical outcomes.