School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
Focused Question:
Which interventions affect the quality of life in individuals with multiple sclerosis?
Prepared By:
Lauren Hawkins, OTS and Cynthia Sanchez, OTS
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV, 89014
Date Review Completed:
October 8th, 2015
Clinical Scenario:
Multiple sclerosis (MS) is a neurodegenerative disease affecting primarily the central
nervous system (National Multiple Sclerosis Society [NMSS], 2010). The specific cause
of MS is unknown, but it is thought to be caused by a combination of environmental and
genetic factors (Foti, 2013). Experts describe MS as an abnormal autoimmune response
where the bodys immune system attacks the healthy tissues, specifically the myelin
sheath surrounding the nerve fibers (Foti, 2013; NMSS, 2010). This attack causes
numerous symptoms.
Early symptoms associated with MS include paresthesia, diplopia, vision loss in one
eye, fatigability, emotional lability, and sensory loss in extremities (Foti, 2013). The most
common symptom of individuals with MS is fatigue (NMSS, 2010.). In advanced stages
of MS, symptoms can lead to varying degrees of paralysis, dysarthria, dysphagia, severe
visual impairment, ataxia, and impaired cognition. While the course of the disease is
unpredictable, it is known that there are four types of MS, each with different
classifications.
The first and most common type is relapsing-remitting MS (RRMS). RRMS is
characterized by early acute attacks with full recovery or with minimal residual deficit

upon recovery (NMSS, 2010). Periods between relapses are when the disease progresses.
Eighty-five percent of individuals with MS are diagnosed with this form of MS.
Approximately 50% of those diagnosed with RRMS will progress into secondaryprogressive MS (SPMS) within five years (NMSS, 2010). After the individual
experiences the initial relapsing-remitting course, they will experience occasional relapses
with minor remissions and plateaus. The next form is primary-progressive MS (PPMS).
This form is characterized by a progression of disability from the onset with no plateaus
and remissions (NMSS, 2010). This form is most likely the most debilitating form and
quite uncommon with only 10% diagnosed with this form (NMSS, 2010). The final type
of MS is progressive-relapsing MS (PRMS) and is the least common with only 5%
diagnosed. PRMS is characterized by the progression from onset with acute relapses with
or without full recovery.
The onset of MS usually occurs between the ages of 20 and 45 years and is more
prevalent in women (Foti, 2013). It is estimated that there are currently approximately
350,000 cases in the United States. MS is a progressive disease that greatly impacts the
quality of life (QOL) of individuals diagnosed with it. Even though there is currently no
cure, there are many ways that as practitioners we can help manage the symptoms and
improve the QOL in this population.
Summary of Key Findings:
Summary of Levels I, II and III:
Education: Research strongly supports that interventions focusing on education can help
improve the QOL in individuals diagnosed with MS. Particularly groups focusing on
various forms of health promotion have been found to be effective. For instance, groups
focusing on lifestyle management and physical activity have shown to increase QOL,
participation in physical activities, and perceived impact of MS (Ennis, Thain, Boggild,
Baker, & Young, 2006; Feys et al., 2012). Furthermore, education-based interventions
have shown to increase the self-efficacy of individuals living with MS. Programs focusing
on teaching self-efficacy strategies and energy conservation techniques have shown
improved self-efficacy, health behaviors, and QOL (Mathiowetz, Finlayson, Matuska,
Chen, & Luo, 2005; Stuifbergen, Becker, Blozis, Timmerman, & Kullberg, 2013).
Exercise: Though clinicians may not commonly use exercise as an intervention for those
with MS due to high levels of fatigue and poor balance, it has been shown to have a
significant impact on the QOL of individuals living with MS (Huisinga, Filipi, & Stergio,
2011; Kargarfard, Etemadifar, Baker, Mehrabi, & Hayatbakhsh, 2012; Ozge, Serkan,
Egemen, & Album, 2012; Tarakci, Yeldan, Huseyinsinoglu, Zenginler, & Eraksoy, 2013).
In addition, researchers have found exercise to actually improve fatigue levels in
individuals with MS. Aquatic exercise and light elliptical training both led to lower scores

of the Modified Fatigue Impact Scale (Huisinga et al., 2011; Kargarfard et al., 2012).
Another main symptom stemming from MS is balance difficulties, and exercise has also
shown to have a positive impact on this. Interventions focusing on strengthening,
flexibility, and balance exercises have significantly improved scores on the Berg Balance
Test (Ozge et al., 2012; Tarakci et al., 2013).
Rehabilitation: Clinicians working in rehabilitation services have a great opportunity to
improve the QOL in persons with MS. Though research is not clear on what type of
services is best for this population, research utilizing three different types of clinicians
(i.e., occupational therapist, physiotherapist, speech therapist) have been found effective
to improving QOL (Patti et al., 2002; Vikman, Fielding, Lindmark, & Fredrikson, 2008).
Vikman et al. (2008) found that interventions as short as three weeks can improve scores
in QOL assessments in an inpatient setting.
Psychosocial: One important aspect of interventions is that they do not only focus on the
physical deficits of the client. Depression is common in those with MS and is correlated
with a lower QOL (Hart, Fonareva, Merluzzi, & Mohr, 2005). However, researchers have
found that treating the depression of individuals with MS does not create a higher QOL
(Hart et al., 2005).
Summary of Level IV and V:
No level IV or V studies were utilized in this review.
Contributions of Qualitative Studies:
No qualitative studies were utilized in this review.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT: All of the research studies noted the
prevalence of low QOL in individuals with MS due to the severity of the symptoms and
decreased participation in meaningful occupations. In addition, the high levels of fatigue
noted tend to further impact their participation and QOL. Due to these circumstances,
occupational therapy (OT) is needed in order to improve functioning, decrease fatigue,
and help with overall QOL whether in a clinical or community-based setting.
Program development: It is important for occupational therapists working with
individuals diagnosed with MS to focus on the impact that the disease has on their QOL.
Occupational therapists should consider the different aspects of QOL when creating

interventions for this population. Research has shown that exercise groups and education
programs offered in the community or rehabilitation settings can be beneficial in reducing
common symptoms of MS and increasing QOL. Programs ranging from three weeks to
twelve weeks have proven to be effective. These programs should focus on self-efficacy,
energy conservation, health promotion, core balance, strengthening, and functional
activities.
Societal Needs: Individuals diagnosed with MS experience a progressive loss of function
that leads to high healthcare costs; thus, it is important for practitioners to help them
maintain their independence as long as possible. Furthermore, it is just as important for
practitioners to help individuals maintain their QOL levels as their disease progresses.
The research studies also noted that individuals with MS have shown reduced physical
activity and reduced self-efficacy. By addressing these factors, occupational therapists can
also improve the QOL of individuals with MS and assist in reducing caregiver burden.
Healthcare delivery and policy: Often exercise and physical activity are thought to be
contraindicated for individuals with MS; however, the research suggests there are
numerous benefits. Exercise and physical activity can not only help manage symptoms
brought on by MS, but also the individual's overall QOL. Other healthcare practitioners
and physicians need to be made known not only of those benefits, but also the
applicability and usefulness of OT in this type of intervention.
Education and training of OT students: Occupational therapists working in a variety of
settings with individuals diagnosed with MS are primarily concerned with the physical
impairments; however, other impairments cannot be ignored. Current OT students need to
be educated on the importance of holistic treatment that includes psychosocial aspects and
factors affecting QOL. Evidence-based practice in regards to appropriate and efficient
interventions need to be taught as well.
Refinement, revision, and advancement of factual knowledge or theory: Future studies
should focus on examining the long-term effects of interventions aimed at impacting QOL
in individuals living with MS. While a few studies completed a follow-up on their
participants, most of the studies did not make an attempt to identify how long the effects
of their interventions lasted; therefore, creating the need for future research. Furthermore,
future studies should attempt to determine what the minimum frequency and duration of
an intervention focused on improving QOL should be.

Review Process:
Explored focus question possibilities based on topic of interest

Focus question compiled, reviewed, and approved by course instructor

Multiple databases were searched and articles were selected based on the inclusion and
exclusion criteria
Revision of focus question by the two reviewers to yield more applicable studies
Full-text articles read and appraised
Additional articles found through hand-searching through reference lists
Articles that met the criteria were critically appraised individually using the McMaster
University Critical Review Form for Quantitative Studies
Critical Review Forms posted weekly for course instructor approval
Evidence table created based on the 11 studies that fit the criteria
Summarized to create critically appraised topic (CAT)
Procedures for the Selection and appraisal of articles:
Inclusion Criteria:

Discuss quality of life

Interventions were within the scope of OT services
Diagnosis of MS (any form)
Adults 18 and older
Articles written in English
Quantitative articles

Exclusion Criteria:

Articles published more than 15 years ago

Persons under the age of 18
Studies with outcomes not reported
Presentations, theses, dissertations
Systematic reviews

Search Strategies:
Categories

Key Search Terms

Patient/Client Population

Adults with multiple sclerosis; Older adults with

multiple sclerosis; Individuals with multiple sclerosis

Intervention

Occupational therapy; Occupational therapy

interventions; Physical activity; Rehabilitation;
Education programs; Wellness programs

Outcomes

Quality of life; Improved quality of life

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched

CINHAL, GoogleScholar, PubMed, EBSCO, OTSearch
Quality Control/Peer Review Process:
To assure relevance and appropriateness, authors had course instructor approve the focus
question
Articles found through database searching were reviewed by authors according to
inclusion and exclusion criteria
The authors completed McMaster University Critical Review Forms for Quantitative
Studies to appraise each article that met the criteria
The authors posted each form on a discussion board online
The authors reviewed each others review forms that were posted on the discussion board
The authors agreed on which articles were appropriate for the CAT after analyzing the
McMaster University Critical Review Forms for Quantitative Studies
The course instructor reviewed the critical appraisal forms, evidence table, and associated
articles
Authors developed CAT which was reviewed by course instructor for clarity and
appropriateness
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence

Study Design/Methodology of Selected Articles

Number of
Articles Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, non-randomized studies (e.g. cohort,

case-control)

III

One group, non-randomized studies (e.g. before and 4

after, pre-test and post-test)

IV

Descriptive studies that include analysis of

outcomes (single subject design, case series)

V

Case reports, expert opinion, which include

narrative literature reviews, and consensus
statements

Other

Qualitative Studies

0
11

TOTAL:
Limitations of the Studies Appraised:
Levels I, II, and III
Small sample sizes
Lack of male participation in studies
Many of the participants were self-selected; therefore, indicating willingness to
comply with the guidelines of the intervention
Potential of training effects from multiple administrations of various assessments
The studies did not look at the long-term effects of the interventions
High rates of attrition due to exacerbations of the disease
Many of the studies were conducted outside of the United States, thus their
methods could have been different
Levels IV and V
No level IV or V studies were utilized.
Other
N/A

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Ennis, M., Thain, J., Boggild, M., Baker, G. A., & Young, C. A. (2006). A randomized
controlled trial of a health promotion education programme for people with
multiple sclerosis. Clinical Rehabilitation, 20(9), 783-792. doi:
10.1177/0269215506070805
Feys, P., Tytgat, K., Gijbels, D., De Groote, L., Baert, I., & Van Asch, P. (2012). Effects of

an 1-day education program on physical functioning, activity and quality of life in

community living persons with multiple sclerosis. NeuroRehabilitation, 33(3),
439-448. doi:10.3233/NRE-130975
Hart, S., Fonareva, I., Merluzzi, N., & Mohr, D. C. (2005). Treatment for depression
and its relationship to improvement in quality of life and psychological well-being
in multiple sclerosis patients. Quality of Life Research, 14(3), 695-703. Retrieved
from http://www.jstor.org.lbproxy2.touro.edu/stable/4038819?seq=1#
page_scan_tab_contents
Huisinga, J. M., Filipi, M., & Stergiou, N. (2011). Elliptical exercise improves fatigue
ratings and quality of life in patients with multiple sclerosis. Journal of
Rehabilitation Research and Development, 48(7), 881-890.
doi:10.1682/JRRD.2010.08.0152
Kargarfard, M., Etemadifar, M., Baker, P., Mehrabi, M., & Hayatbakhsh, R. (2012). Effect
of aquatic exercise training on fatigue and health-related quality of life in patients
with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 93(10),
1701-1708. doi: 0003-9993/12/9310-00538
Mathiowetz, V. G., Finlayson, M. L., Matuska, K. M, Chen, H. Y., & Luo, P. (2005).
Randomized control trial of an energy conservation course for persons with
multiple sclerosis. Multiple Sclerosis, 11 592-601. doi:
10.1191/1352458505ms1198oa
Ozge, E., Serkan, O., Egemen, I., & Algun, Z. C. (2012). Quality of life, fatigue, and
balance improvements after home-based exercise program in multiple sclerosis
patients. Archives of Neuropsychiatry, 49(1), 33-38. doi: 10.4274/npa.y6091

Patti, D., Ciancio, M. R., Reggio, E., Lopes, R., Palermo, F., Cacopardo, M., &
Reggio, A. (2002). The impact of outpatient rehabilitation on quality of life in
multiple sclerosis. Journal of Neurology, 249(8), 1027-1033. doi: 10.1007/s00415002-0778-1
Stuifbergen, A. K., Becker, H., Blozis, S., Timmerman, G., & Kullberg, V. (2003). A
randomized clinical trial of a wellness intervention for women with multiple
sclerosis. Archives of Physical Medicine and Rehabilitation, 84(4), 467-476.
doi:10.1053/apmr.2003.50028
Tarakci, E., Yeldan, I., Huseyinsinoglu, B. E., Zenginler, Y., & Eraksoy, M. (2013). Group
exercise training for balance, functional status, spasticity, fatigue and quality of
life in multiple sclerosis: A randomized controlled trial. Clinical Rehabilitation,
27(9), 813-822. doi: 10.1177/0269215513481047
Vikman, T., Fielding, P., Lindmark, B., & Fredrikson, S. (2008). Effects of inpatient
rehabilitation in multiple sclerosis patients with moderate disability. Advances in
Physiotherapy, 10(2), 58-65. doi: 10.1080/14038190701288785

Other References:
Foti, D. (2013). Multiple sclerosis. In H. M. Pendleton & W. Schult-Krohn (Eds.), Pedretti's
occupational therapy: Practice skills for physical dysfunction (7th ed., pp.936-940). St.
Louis, MO: Elsevier.
National Multiple Sclerosis Society. (2010). Disease overview. In R. Kalb (Ed.), Multiple
sclerosis: A focus on rehabilitation (5th ed., pp. 5-23). Retrieved from

http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures
/A-Focus-On-Rehabilitation_Final-Links.pdf

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05