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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project


Date: October 8th, 2015

Name: Lauren Hawkins, OTS and Cynthia Sanchez, OTS
Focus Question: Which interventions affect the quality of life in individuals with multiple sclerosis?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Inclusion criteria: This inclusion criteria was used to help increase the quality of our critically appraised topic (CAT) and support our focus question.
-Discuss quality of life
-Interventions were within the scope of occupational therapy services
-Diagnosis of multiple sclerosis (any form)
-Adults 18 and older
-Articles written in English
-Quantitative articles
Exclusion criteria: The exclusion criteria was used to help remove articles from our search that did not support our focus question.
-Articles published more than 15 years ago
-Persons under the age of 18
-Studies with outcomes not reported
-Presentations, theses, dissertations
-Systematic reviews




Intervention and
Outcome Measures



Implications for OT

Ennis, Thain,
Boggild, Baker,
& Young (2006).

-To evaluate the

effectiveness of
a health
program for
individuals with
sclerosis (MS)
looked at
increasing the
level of healthpromoting
improvement in
self-efficacy, and
enhancement of
quality of life

-Level I
Controlled Trial
-Subjects: 61
participants all
with a diagnosis
of MS
ranged from 1865 years of age
-38 participants
were female and
23 were male
-32 participants
were in the
treatment group
and 30 were in
the control group

-Intervention: OPTIMISE
was an outpatient health
promotion education
program aimed at
increasing knowledge,
skills, and confidence
-It was delivered over 8
weekly sessions of 3
-Group format
-Education divided into 5
components (exercise and
physical activity, lifestyle
adjustment and fatigue
management, stress
management, nutritional
awareness, and
responsible health
-Measures: Health
Promoting Lifestyle
Profile II (HPLP);
Self-Rated Abilities for
Health Practices Scale
36-Item Short Form
Health Survey (SF-36)

-The treatment group had

significant higher levels of
health promotion (p<0.01)
and self-efficacy for
health promotion
activities (p< 0.01)
-Improvements were
noted in physical health
(p=0.03), mental health
(p< 0.01) and general
health (p< 0.01) aspects of
-Benefits were sustained
for 3 months after the

were not
blinded as to
what group
they were in
on health
-Did not look
at the long
term benefits
of the

-Clinical & Community-Based Practice of

OT: This study demonstrates that a once-aweek outpatient program is beneficial in
reducing common symptoms of MS and
increasing QOL.
-Program Development: A consistent program
similar to OPTIMISE should be implicated in
the community.
-Societal Needs: The benefits of health
promotion activities are widely acknowledged
within the general population and have been
positively correlated with increasing the QOL
of individuals with MS.
-Healthcare Delivery & Policy: It is important
for health care professionals to address health
promotion education in order to provide
individuals with the appropriate level of
knowledge, skills, and confidence to allow
them to make informed decisions regarding
their health choices.
-Education & Training of OT Students: We
need to educate students on the benefits of the
exercise and fatigue management for those with
MS. Exercise is often considered off limits for
those with MS due to high fatigue levels.
However, research supports the use of exercise
during interventions.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Further
research needs to examine the benefits of this
type of program for long-term. In addition,
research should be completed to see if similar
results could be achieved with less of a time
commitment for outpatient services.

Feys, Tytgat,
Gijbels, De
Groote, Baert, &
Van Asch (2012).

-To investigate
effects of a one
day education
program about
exercises and
sports, physical
behavior, related
measures as selfefficacy,
walking ability,
fatigue, and
perceived impact
of MS and QOL.

- Level III
-Single Case
-Subjects: 42
dwelling adults
with MS
-9 males and 33
-The researchers
divided the
participants into
two groups based
on self-report of
gait disability (24
with no gait
disability and 18
with gait
-Originally had
57 participants15 dropped for

Participants attended a
one-day workshop
involving physical activity
and exercise
-The first half of the
workshop was a
theoretical session
regarding exercise and
sports in MS
-The second half allowed
participants to experience
3 different types of fitness
and were given 6 options.
-Each mini-session lasted
45 minutes
Patient Determined
Disease Steps (PDDS);
Physical Activity Scale for
Individuals with Physical
Disabilities (PASIPD);
12-item MS Walking
Scale (MSWS-12);
Exercise Self-Efficacy
Scale (ESES);
Modified Fatigue Impact
Scale (MFIS);
Multiple Sclerosis Impact
Scale (MSIS-29); SF-36
-Measures were taken on
education day, at 3
months, and at 6 months.

-Results showed that at 3

and 6 months there was a
significant increase in the
physical activity level for
the subgroup with no gait
-Significant changes were
found for both subgroups
regarding perceived levels
of disability as measured
by the PDDS (group 1
p=0.06; group 2 p=0.07)
-Significant increases
(p<0.01) were also found
using the SF-36,
indicating that QOL
increased for both groups
due to consistent

sample size
-The study
only applies
to persons
with MS who
are ready and
willing to
not generalize
to all persons
with MS
-The groups
were divided
into gait
disability and
no gait
disability by

-Clinical & Community-Based Practice of

OT: Exercise groups and classes in the
community can help increase the QOL and
physical activity in individuals with MS.
-Program Development: Single education
days can be valuable in practice and may
enhance physical activity behavior in
individuals with perceived disabilities and
should be readily available.
-Societal Needs: Individuals with MS in the
community have shown reduced physical
activity and reduced self-efficacy in terms of
physical activity; however, research has shown
that exercise can be beneficial to this
-Healthcare Delivery & Policy: Interventions
should include some form of promoting
education on exercise.
-Education & Training of OT Students: All
students should be educated on the importance
of exercise within the MS population and that
these individuals still have the ability to
exercise if done in moderation.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Further
research should be conducted in regards to
expanding this program to more than one day
(e.g., 1/wk for 3 months).

Hart, Fonareva,
Merluzzi, &
Mohr (2005).

-To examine the

impact of
depression in
individuals with
MS and the
impact that has
on their QOL

-Level III
-Before and After
-Subjects: 60
participants with
an average age of
44.8 years
- 26.7% males;
73.3% females
-All participants
had a score of at
least 16 on the
Beck Depression
Inventory (BDI)
-Each participant
was randomly
assigned to
receive 1 of 3
types of

Participants were
randomly assigned to 1 of
3 depression treatments
(cognitive behavioral
therapy [CBT],
group psychotherapy
[SEGP], or Sertraline
-There was no control
group and each participant
stayed with their treatment
for 16 weeks
Multiple Sclerosis Quality
of Life Question-54
(MSQOL-54); BDI; 25foot walk, and
Psychological Well-Being
(PWB) scales

-5 out of 6 components in
the PWB scales were
statistically significant:
autonomy (p=0.005),
environmental mastery
(p<0.001), purpose in life
(p<0.001), self-acceptance
(p=0.003), personal
growth (p=0.021)
-BDI scores were found to
predict follow-up scores
for the MSQOL-54
-No treatment found to
both decrease depression
and improve QOL

sample size
-No control
group to
compare the
determine if
the results are
due to
placebo effect

-Clinical & Community-Based Practice of

OT: Therapists should take into account the
different aspects of QOL when creating
interventions. It would be more beneficial to
incorporate mental health with physical
-Program Development: Interventions should
focus on a holistic point of view to increase
QOL. Well-rounded support groups can be used
to help decrease depression, but its also
important to focus on improving physical
-Societal Needs: 27-54% of individuals with
MS also suffer from depression, which
decreases QOL. Thus its important to address
depression in addition to the physical
impairments experienced.
-Healthcare Delivery & Policy: Encourage the
MS population to receive treatment for
depression in addition to physical impairments.
-Education & Training of OT Students:
Students should be taught to look at a client
holistically and not just one part of the client
(e.g. depression).
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Further
research should look at the effects of programs
focusing on both mental health and physical
impairments instead of just one or the other.

Huisinga, Filipi,
& Stergiou

-To evaluate the

effects of
exercise on

-Level III
-Single Case
-Subjects: There

-Intervention: Participants
completed 15 sessions of
elliptical exercise training
over the span of 6 weeks

-The results showed

significant improvements
in the FSS, MFIS, and SF36 subscales

sample size
-No followup was

-Clinical & Community-Based Practice of

OT: Regular elliptical exercise can be a part of
outpatient MS rehabilitation programs as a
preparatory activity to manage symptoms, such

Baker, Mehrabi,
& Hayatbakhsh

fatigue and QOL

reports in
individuals with

were 26
participants all
with clinically
diagnosed MS
-5 of the
participants were
male and 21
were female
could not have
had an
within the past
60 days

-Each session lasted 30

minutes and heart rate was
monitored every 3
-Participants began with
the elliptical machine set
at an incline of 0 and a
resistance of 1; intensity
was increased every 3-4
sessions by increasing the
resistance level or the
-Measures: Fatigue
Severity Scale (FSS);

-Scores of the FSS

significantly decreased
from 4.89 +/- 1.32 to 4.32
+/-1.57 (p=0.008)
-SF-36 subscale scores of
Physical Function
significantly increased
(p=0.013); Role emotional
significantly increased
(p=0.015); Energy
significantly increased
(p<0.0001); Social
Function increased
(p=0.009); General Health
significantly increased
-Change in FSS due to
elliptical exercise
significantly correlated
with change in SF-36
Physical Function
subscale (R = 0.42; p =
0.043) and Role Physical
subscale (R=-0.52;

completed to
-No control

as fatigue.
-Program Development: It has been shown
that 6 weeks of elliptical exercise training can
significantly improve fatigue and QOL in
individuals with MS; thus, when developing a
program it should be at least 6 weeks in length.
-Societal Needs: Research shows that an
exercise program utilizing common equipment
can be beneficial in reducing fatigue and
increasing QOL.
-Healthcare Delivery & Policy: All healthcare
practitioners should encourage an exercise
program utilizing the elliptical, as it is easily
accessible for all individuals.
-Education & Training of OT Students:
Students should be educated on the benefits of a
light exercise program on the MS population.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research should include a longer program
duration to assess the full benefits of this
exercise program.

-To examine the

effectiveness of
aquatic exercise
training on
fatigue and
QOL in
individuals with

-Level I
Controlled Trial
-Subjects: 32
participants with
a diagnosis of

-Intervention: Treatment
group received 8 weeks of
aquatic exercise
-Sessions were 60
minutes, 3 times a week
-Each session consisted of
a 10-minute warm-up, 40

-Participants in treatment
group had lower MFIS
scores (p<0.01) at both 4
and 8 weeks
-Significant differences in
both physical (p<0.01)
and mental health
(p<0.05) composite scores

number of
consisted of
only females
when that was
not one of the

-Clinical & Community-Based Practice of

OT: Clinicians should utilize aquatic and landbased interventions based on the symptoms and
interests of the client.
-Program Development: Occupational
therapists could develop a program similar to
the one in the study that only includes aquatic
exercise as the benefits are supported.

Matuska, Chen,
& Luo (2005).


-Mean age: 32.6

were randomly
assigned to the
treatment group
or exercise group
by a neurologist
who had no other
using a shuffled
sealed envelopes

minutes of exercise, and a

10-minute cool-down
-Aquatic exercises
focused on joint mobility,
muscle strength, balance,
posture, functional
activities, and intermittent
-Control group
participants were asked to
maintain their current
treatment throughout the 8
week study
-Measures: MFIS;

of HRQOL in treatment
-Overall, participants in
treatment group showed
significant improvement
in fatigue and healthrelated QOL after both 4
and 8 weeks

variables in

-Societal Needs: Individuals with MS are

likely to display depressive symptoms and
withdrawal from enjoyable activities. Aquatic
exercise may serve as a form of exercise and
reengagement in leisure activities.
-Healthcare Delivery & Policy: Aquatic
exercise programs are beneficial to reducing
fatigue and increasing QOL in individuals with
MS. This form of exercise has low impact on
the joints, which allows them to participate in
-Education & Training of OT Students:
Students should be reminded that therapy
sessions may occur in a variety of settings
including a pool.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research should investigate the effectiveness of
aquatic exercise in individuals with more severe
disability and to compare the effects of aquatic
exercise to land-based interventions.

-To assess the

efficacy and
effectiveness of
a 6-week energy
(EC) course on
fatigue impact,
QOL and selfefficacy for
individuals with

-Level I
Controlled Trial
-Subjects: 169
participants with
a diagnosis of
MS over the age
of 18
-Power analysis
used to justify
sample size

-Intervention: The EC
course was 2 hours long,
once a week for 6 weeks
-Course administered by
12 occupational therapists
-Quizzes administered to
make sure participants
understood material
-Group1 received the EC
course during weeks 2-7,
while group2 received it
weeks 8-13

-The intervention group

was significantly different
from the control group
-The vitality subscale of
the SF-36 was
significantly different
-All three subscales of the
FIS were significantly
different (p<0.05)

attrition rate
of 23%
-There were
between the
number of

-Clinical & Community-Based Practice of

OT: Community courses focusing on teaching
EC techniques to individuals living with MS
can help them learn the skills necessary to
reduce their fatigue and improve their overall
-Program Development: Occupational
therapists should keep in mind that energy
conservation courses are an acceptable nonpharmacological way of treating fatigue and
QOL in individuals living with MS when
planning treatments.

Ozge, Serkan,
Egemen, &
Algun (2012).

-To determine
the effects of a
program (HEP)
on aspects of
fatigue and
balance in adults
diagnosed with

divided into 2
group (group1)
or delayed
control group

-Measures: Fatigue impact

scale (FIS); SF-36;
Self-Efficacy for
Performing EC Strategies

-Level III
-Single Case
-Subjects: 31
participants with
a mean age of
43.6 years
-16 females and
15 males
-They all had a
clinical diagnosis
of MS and could
not have had an
exacerbation in
the past 30 days

- Intervention:
Participants were
provided with the same
instructions regarding the
number of repetitions and
sets to complete and the
frequency of exercise (i.e.,
-Each workout session
consisted of: a warm-up
(5-10min), strengthening
and balance exercises (2025min), and a cool-down
-Measures: EDSS;

-Societal Needs: Fatigue is one of the main

symptoms of MS and affects almost every
aspect of an individuals day and QOL; thus its
important to find methods to help reduce this
-Healthcare Delivery & Policy: This type of
EC courses can be delivered by occupational
therapists in various settings such as outpatient
and inpatient rehab.
-Education & Training of OT Students:
Students should be taught on the effects of EC
and different techniques to remain clientcentered.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research should look at what the minimum
length of these courses should be in order for
them to be effective.
-The researchers found
significant improvements
in balance function
-A significant negative
correlation was found
between QOL and fatigue
scores and a significant
positive correlation was
found between QOL and

-The study
outside of the
United States,
thus the
standards for
the research
were different
sample size

-Clinical & Community-Based Practice of

OT: The benefits of exercise have proven to be
significant and thus exercise should be
incorporated into practice when possible when
working with individuals diagnosed with MS.
-Program Development: Home exercise
programs including balance and strengthening
should be developed to help increase the QOL
and self-efficacy of individuals diagnosed with
-Societal Needs: Individuals diagnosed with
MS commonly experience lower QOL, as
therapists we need to address the psychosocial
components that accompany this diagnosis and
the current study demonstrated that this can be

FIS (Turkish version);

Berg balance scale;
ABC scale;
Multiple sclerosis
international quality of
life (MusiQoL)

Patti, Ciancio,
Reggio, Lopes,
Cacopardo, &
Reggio (2002).

-To evaluate the

effects of a
treatment on
QOL in
individuals with

-Level I
Controlled Trial
-Subjects: 111
individuals with
a diagnosis of
-47 men (42%)
and 64 women
-All participants
were blindly
randomized and
divided into 2
(treatment, n=58)
and home

The outpatient group
received outpatient
therapy services 6x/week
for 50-90 minutes
-Each session was
individualized to the client
-HEP was not discussed in
-Measures: SF-36; BDI;
Tempelaar Social
Experience Checklist; FIS

done by using exercise.

-Healthcare Delivery & Policy: All healthcare
practitioners should encourage exercise for the
MS population even if it is not intense, as the
benefits are significant and supported by
-Education & Training of OT Students:
Students should be educated on the benefits of
HEP and how to create an effective HEP for the
MS population.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research should examine the benefits of a HEP
requiring participation 3-4 times per week to
see if there are still significant benefits.
-Treatment group
improved on all scales of
the SF-36
-Difference between
treatment and control
groups was significant
(p<0.001) for all scales,
except for role functioning
emotional (p<0.005)
-Treatment group reduced
in fatigability, improved
social functioning, and
depression (p<0.001)

forms of
therapy so we
which one
contributed to
the benefits
provided no
regarding the
duration, or
contents of

-Clinical & Community-Based Practice of

OT: OT given through an intensive outpatient
rehabilitation program can benefit individuals
with MS.
-Program Development: Programs that
include a combination of OT, physiotherapy,
and speech therapy can be beneficial to helping
individuals with MS improve their QOL and
-Societal Needs: While rehabilitation has
proven to be beneficial to individuals with MS,
there has not been one specific type of
rehabilitation proven to be the most effective.
This study showed that outpatient therapy can
be beneficial in increasing QOL and functional
-Healthcare Delivery & Policy: Physicians
should refer MS patients not only to physical

exercise (control,

Becker, Blozis,
Timmerman, &
Kullberg (2013).

-To examine the

effects of a
program for
women with MS
on health
behaviors and

-Level I
Controlled Trial
-Subjects: 113
participants with
a mean age of
45.79 years
-A power
indicated they
needed at least
110 participants
-66 participants
were in the
control group
and 76 were in
the treatment

-Intervention: The
program was divided into
2 phases: an educational
and skill-building lifestyle
change program and a
supportive telephone
-The 1st phase consisted
of 8 sessions lasting 90
minutes over an 8-week
-The sessions consisted of
providing information,
guiding participants to
self-assess their behaviors,
resources and barriers,
and supporting selfefficacy strategies
-The 2nd phase involved
the participants receiving

-The study found that the

wellness intervention for
women with MS was
effective in improving
self-efficacy, health
behaviors, and selected
aspects of QOL
-The aspects of QOL that
were most affected were
pain and mental health

the HEP

therapy, but also occupational therapy, as

benefits have been found in the literature.
-Education & Training of OT Students: Even
though individuals with MS experience
progressive losses due to their disease, they do
make good candidates for rehabilitation.
Students need to be taught that there is potential
for functional gains.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research needs to examine the long-term
benefits of intensive outpatient services on
individuals diagnosed with MS.

- Participants
were more
interested in
than other
women with
participants in
the study also
food diaries,
protocols, 6
minute walks,

-Clinical & Community-Based Practice of

OT: Wellness programs delivered through an
outpatient setting can help women with
disabling chronic conditions develop skills that
can influence their attitudes and health
-Program Development:
-Societal Needs: Women with chronic diseases
on average spend twice as long disabled before
death as men while also holding many
household duties. Therefore, we need to focus
on improving QOL and health for this
-Healthcare Delivery & Policy: Wellness
programs can be helpful in providing women
with MS with the information needed to
develop the skills required to influence their
attitudes and improve their overall QOL.
-Education & Training of OT Students:
Students should be trained in the importance of

phone calls twice a month

to encourage progression
toward goals
Incapacity Status Scale;
Barriers to Health
Promoting Activities for
Disabled Persons Scale;
Personal Resource
Self Rated Abilities for
Health Practices; SF-36;
Health Promoting
Lifestyle Profile II
Tarakci, Yeldan,
Zenginler, &
Eraksoy (2013).

-To determine
the effectiveness
of group
exercise training
on balance,
functional status,
fatigue and QOL
in individuals
with MS

-Level I
Controlled Trial
-Subjects: 99
individuals with
a diagnosis of
-64 female (65%)
and 35 male
-Power analysis
completed and
concluded that a
minimum sample
of 44 participants
were randomly
assigned to either

-Interventions: Three 60
minute sessions conducted
by physical therapists for
12 weeks
-The program included
flexibility, range of
motion (ROM),
strengthening, core
stabilization, balance,
coordination exercises,
and functional activities
-Participants were also
educated on exertion
levels and were allowed to
take breaks if they
reached 13/20 on a scale
of perceived exertion
Berg Balance Scale; 10-

-Improvements were
found for the control
group (p<0.01)
-Participants had
significant negative
changes on the Berg
Balance Test (p=0.002)
and the 10-meter walk test
-An increase in QOL
scores was also found

and goal
scaling which
could have
influenced the

educating individuals with MS on health

promotion behaviors and giving them the
resources required to develop the skills needed
to improve their QOL.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Future
research should examine the effects of this
intervention on men as well as other chronic

-Study was
single blinded
which could
have resulted
in potential
effect in the
was not
assessed and
this is a
with MS that
could have
had an impact

-Clinical & Community-Based Practice of

OT: Occupational therapists could incorporate
elements of this program in clinical or
community-based practice as a part of their
-Program Development: Group exercise
training programs combining balance,
coordination, strengthening, flexibility, core
stabilization and functional activities is
effective in improving balance, functional
status, spasticity, fatigue, and QOL in
individuals moderately affected with MS.
-Societal Needs: Some of the most common
clinical features of MS include fatigue, motor
weakness, spasticity, poor mobility and balance,
gait disturbances and an increased risk of
falling; thus, it is imperative that we find what
interventions can help manage these symptoms

Lindmark, &

-To evaluate the

effects of 3
weeks of
on for
individuals with
disability due to

control or
treatment group
by a neurologist
using the
function of
Microsoft Office
Excel software

meter walk test; 10-stair

climbing test; Modified
Ashworth Scale; Fatigue
Severity Scale;
Multiple Sclerosis
International Quality of
Life Questionnaire

-Level II
-Cohort design
-Subjects: 57
participants with
a mean age of
55.8 years
-46 female and
12 male
were divided into
two groups:
cohort A (n=40)
and cohort B

-Intervention: Participants
in the cohort A received
an average of 15
physiotherapy and 9 OT
sessions in 3 weeks
-30 min physiotherapy
(strength, mobility,
balance, aquatic exercise)
& OT (hand-training)
sessions were provided
-Measures: Mean
Expanded Disability

-Cohort A improved
significantly in areas QOL
(p<0.05), 9-hole peg test,
Box and Block Test, Berg
Balance Scale, MSFC,
and COVS (p<0.01)
-Cohort B improved
significantly in emotional
well-being (p<0.05), Box
and Block Test, 25-foot
walk test, and MSFC

on fatigue

-Healthcare Delivery & Policy: Some

healthcare professionals may think that strength
training is contraindicated for the MS
population; however, research supports its use
in practice. Other healthcare professionals need
to be educated on the benefits of this type of
-Education & Training of OT Students:
Though we do not consistently promote
biomechanical interventions, students should be
educated on the benefits and ways to
incorporate those techniques into occupationbased activities.
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: The current
study focused only on individuals who were
moderately impaired, future research should
look at the effects of such an intervention in
individuals who are mildly or severely

-The 2
cohorts were
not even in
-Possible bias
in results due
to training
effects from
-Sample size
consisted of

-Clinical & Community-Based Practice of

OT: We suggest creating an intensive 3-week
community group or outpatient group that
mirrors the treatment provided in this group in
order to provide the services outside of
inpatient rehabilitation.
-Program Development: 3 weeks of inpatient
rehabilitation is sufficient to achieve significant
improvements in QOL; due to this, inpatient
occupational therapy programs should be
created specifically for individuals with MS.
-Societal Needs: Individuals with MS
experience progressive loss of function which


Status Scale;
Barthel Index of ADL
(BI); Fatigue Severity
Scale (FSS); SF-36;
Functional Assessment of
Multiple Sclerosis
(FAMS); BDI; Multiple
Sclerosis Functional


leads to high healthcare costs, thus its

important to find which interventions can help
them maintain their independence as long as
-Healthcare Delivery & Policy: Physicians
should recommend and refer patients with MS
to occupational therapy as research supports the
benefits even after only 3 weeks.
-Education & Training of OT Students: We
need to educate students on the impact that we
as practitioners can have while working in an
inpatient setting on those with MS. 3 weeks has
been found to be enough time to improve QOL
and other aspects of their health
-Refinement, Revision, & Advancement of
Factual Knowledge or Theory: Further
research should be conducted on the long-term
effects of inpatient rehabilitation to note how
long the benefits can last.