RESEARCH SCHOLARS INITIATIVE
Five-Year Retrospective Study of Inpatient Occupational
Therapy Outcomes for Patients With Multiple Sclerosis
KEY WORDS
 activities of daily living
 medical audit
 multiple sclerosis
 occupational therapy
 rehabilitation
 treatment outcome
Kinsuk Maitra, PhD, OTR/L, is Associate Professor,
Occupational Therapy Department, Rush University
Medical Center, 600 South Paulina, Suite 1011, Chicago,
IL 60612; Kinsuk_Maitra@rush.edu
Carole Hall, OTR/L, is Occupational Therapist,
Occupational Therapy Department, Rush University
Medical Center, Chicago.
Terri Kalish, COTA/L, is Senior Occupational Therapy
Assistant, Occupational Therapy Department, Rush
University Medical Center, Chicago.
Marita Anderson, MS, OTR/L; Erin Dugan, MS,
OTR/L; Justine Rehak, MS, OTR/L; Verónica
Rodrı́guez, MS, OTR/L; Jennifer Tamas, MS,
OTR/L; and Deborah Zeitlin, MS, OTR/L, are
Graduate Students, Occupational Therapy Department,
Rush University Medical Center, Chicago.
The American Journal of Occupational Therapy
Kinsuk Maitra, Carole Hall, Terri Kalish, Marita Anderson, Erin Dugan,
Justine Rehak, Verónica Rodrı́guez, Jennifer Tamas, Deborah Zeitlin
OBJECTIVE. This study was a retrospective chart analysis spanning 5 yr that investigated asso-
ciations between occupational therapy interventions and goal-based positive outcomes in patients
with multiple sclerosis (MS) and related disorders at discharge in an urban inpatient rehabilitation
setting.
METHOD. Using descriptive statistics, we examined demographic characteristics in the first analysis phase.
In the second phase, we performed a series of correlational analyses to identify treatment variables associated
with positive outcomes.
RESULTS. Generally, patients improved in their FIM™ scores at discharge. Increasing occupational
therapy intensity had a positive effect on functional performance in all categories except feeding, with
significant correlations in upper-extremity dressing (r 5 .153, p < .05) and memory (r 5 .204, p < .01).
CONCLUSION. Occupational therapy was associated with positive functional outcomes for patients
with MS. Future treatment protocols should include cognitive skills training, community reintegration,
and self-care, because these treatments were found to be significantly correlated with positive changes
in FIM scores.
Maitra, K., Hall, C., Kalish, T., Anderson, M., Dugan, E., Rehak, J., et al. (2010). Research Scholars Initiative—
Five-year retrospective study of inpatient occupational therapy outcomes for patients with multiple sclerosis.
American Journal of Occupational Therapy, 64, 689–694. doi: 10.5014/ajot.2010.090204
M ultiple sclerosis (MS) and related disorders (Devic’s disease, or neuro-
myelitis 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 &
689
Tickle-Degnen, 2001; Mathiowetz, Finlayson, Matuska,
Chen, & Luo, 2005; Matuska, Mathiowetz, & Finlay-
son, 2007).
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 rehabilita-
tion 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). Simi-
larly, a study by Solari et al. (1999) found that inpatient
rehabilitation can clinically and statistically reduce dis-
ability 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 oc-
cupational 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 occupa-
tional 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 occupa-
tional therapy interventions that focus on energy con-
servation 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 5 44) of patients with MS receiving occupational
690
therapy services were satisfied or very satisfied with their
treatment and thought that it was important or very im-
portant 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
Sample
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 dis-
charge. 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.
Procedure
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 assess-
ment, expected performance, and discharge performance.
Occupational therapy interventions included were hot–cold
packs, sensory integration, manual therapy, massage, con-
trast 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’
September/October 2010, Volume 64, Number 5
functional performance by extracting the patient’s initial between discharge and initial FIM was examined by paired
assessment, goal, and discharge FIM scores. t test.
The FIM is a standardized evaluation tool with
high reliability and validity (Dodds, Martin, Stolov, & Results
Deyo, 1993). FIM scores were recorded for feeding,
grooming, bathing, upper-extremity dressing, lower- Descriptive statistics were used in examining patient
extremity dressing, toileting, toilet transfers, tub or shower charts. Patient demographic information is provided in
transfers, comprehension, expression, social interaction, Table 1. Multiple sclerosis accounted for 92.7% (n 5
problem solving, and memory. One data capture sheet was 179) of the population, followed by related disorders
completed for each patient’s hospital stay. We collected (4.7%, n 5 9). Most patients were female (76.7%; n 5
demographic information, without any patient-identifying 148) and living at home before hospitalization (93.7%;
information, on the demographic information sheet. No n 5 181). The mean length of stay was 13.34 days (SD 5
direct patient identifiers were collected. 6.31), and the patients received occupational therapy
All medical charts were retrieved from the Rush treatments on approximately 56% of the days that they
University Medical Center’s medical records office and were in the inpatient setting (Table 2). Most patients
returned to the office after data were extracted. Data were discharged to home (79.8%; n 5 154), and only
collection sheets were kept in a secure, locked office at the 8.8% (n 5 17) were transferred to a skilled nursing fa-
hospital. Two lead occupational therapy clinicians from cility (Table 1). The most common occupational therapy
the Rush University Medical Center trained research interventions were self-care, therapeutic exercise, and
students on proper protocol for data extraction from the occupation-based therapeutic activities (Table 2). In
medical charts. To ensure high interrater reliability, all general, all patients showed improvement in their total
study staff demonstrated 100% proficiency over five trials FIM scores (Table 3). The greatest improvements were
with the data capture sheet and demographic information seen in ADLs (transfers, toileting, dressing, and bathing).
sheet before they extracted data independently. The study To assess the effectiveness of occupational therapy
clinicians and principal investigator ensured proper interventions in terms of improving functional independence
training of all staff so that all data would remain confi- in patients with MS, we conducted a Pearson’s correlation
dential and Health Insurance Portability and Account-
Table 1. Client Demographics (N 5 193)
ability Act and personal health information requirements
would not be violated. Demographic Information % n
Gender
Data Entry and Analysis Male 23.3 45
Female 76.7 148
Once the team had collected data from all 193 patient Race*
charts, study staff entered the information into the statistics White 45.1 87
database (SPSS–15; SPSS, Inc., Chicago). Data quality African-American 43.0 83
assurance included systematic training for research and Other 8.3 16
clinical staff for data entry, interrater reliability monitor- Primary diagnosis
Multiple sclerosis 92.7 179
ing, and electronic data verification. All data collected and
Related disorder 7.2 14
entered into the database were entered by a primary rater Marital status
and then verified by a secondary rater to ensure high re- Never married/single 33.7 65
liability. Information missing from chart entries was Married 42.1 81
identified in the process and verified for accuracy. Divorced 14.1 27
Initial data analysis included exploratory descriptive Widowed 5.7 11
Prehospital living setting
statistics. In the second series of analyses, we performed
Home 93.8 181
a series of correlation analyses to identify the relationship Skilled nursing facility 2.1 4
between treatment variables and functional outcomes. The Posthospital living setting
treatment variables examined were occupational therapy Home 79.8 154
intensity (number of occupational therapy treatment days/ Skilled nursing facility 8.8 17
length of stay) and functional outcomes. In addition, we Acute care 4.7 9

examined the relationship between the number of therapy *Percentages are based on an N of 193, but some data are missing: 7
participants did not disclose race, 9 did not disclose marital status, 8 did
minutes spent in each intervention and the change in FIM not disclose prehospital living setting, and 13 did not provide posthospital
scores for each functional activity. Significant difference living setting.

The American Journal of Occupational Therapy 691

Table 2. Intervention Characteristics
Category Mean Standard Deviation Range
Age 47.13 13.05 18–77
Length of stay, days 13.34 6.31 2–37
Occupational therapy interventions, days 7.56 4.34 1–25
No. of treatment sessions/staya 7.75 4.72 1–27
Occupational therapy intensityb 0.56 0.14 0.11–0.88
Total duration of occupational therapy interventions, min 434.22 335.62 15–3,300
Total intervention time (min) spent in
ADLs/self-care 168.38 155.15 0–990
Therapeutic activity 125.34 117.78 0–735
Therapeutic exercises 67.78 75.36 0–435
Neuromuscular reeducation 13.22 32.23 0–180
Cognitive training 4.21 17.68 0–180
Note. ADLs 5 activities of daily living.
a
Each session duration was approximately 55–60 min.
b
Occupational therapy intensity is calculated as number of occupational therapy treatment days divided by length of stay.

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 in-
tensity 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 5 .15,
p < .05) and memory (r 5 .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 5 .23, p < .01) and
expression (r 5 .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 5 .24, p < .01), and toilet transfers (r 5 .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 5 2.17, p < .05) and tub transfers (r 5 2.21, 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 5 .21, p < .01) and a negative impact on tub
transfers (r 5 2.18, p < .05; Table 5).
Discussion
Occupational therapy is a part of the rehabilitation team
that serves patients with MS during inpatient re-
habilitation stays. The purpose of occupational therapy is
to facilitate independence and participation in ADLs.
Results from this study suggest that occupational thera-
pists in an inpatient rehabilitation center were able to help
achieve this purpose, because patients with MS who

Table 3. Change in Discharge FIM Status Compared With Initial FIM Scores: Paired t Test
Initial FIM Discharge FIM FIM Change Standard Error of
FIM Category M (SD) M (SD) M (SD) FIM Change t (df ) p (2-tailed)
Feeding 5.06 (1.37) 5.84 (1.00) 0.78 (1.14) 0.084 9.272 (184) .000
Grooming 4.61 (1.27) 5.46 (0.98) 0.85 (1.15) 0.085 10.107 (184) .000
Bathing 3.16 (1.39) 4.37 (1.17) 1.21 (1.28) 0.094 12.838 (184) .000
Upper-extremity dressing 4.07 (1.17) 5.12 (0.94) 1.05 (1.10) 0.081 12.969 (184) .000
Lower-extremity dressing 2.83 (1.41) 4.18 (1.47) 1.35 (1.20) 0.088 15.282 (184) .000
Toileting 2.37 (1.71) 4.15 (1.66) 1.78 (1.67) 0.124 14.354 (182) .000
Toilet transfer 2.72 (1.72) 4.36 (1.46) 1.64 (1.36) 0.101 16.278 (183) .000
Tub transfer 0.50 (1.10) 3.42 (1.87) 2.93 (1.90) 0.145 20.202 (182) .000
Comprehension 5.66 (0.94) 5.92 (0.85) 0.25 (0.84) 0.063 3.970 (179) .000
Expression 6.02 (0.98) 6.39 (0.77) 0.36 (0.90) 0.067 5.373 (179) .000
Social interaction 5.95 (0.96) 6.26 (0.75) 0.36 (0.84) 0.066 5.470 (162) .000
Problem solving 5.64 (1.15) 6.08 (0.93) 0.43 (0.94) 0.070 6.069 (179) .000
Memory 5.82 (1.20) 6.20 (1.00) 0.36 (1.12) 0.084 4.316 (179) .000
Note. M 5 mean; SD 5 standard deviation; df 5 degrees of freedom.

692 September/October 2010, Volume 64, Number 5

Table 4. Correlations: Occupational Therapy Intensity Table 5. Number of Occupational Therapy Minutes Spent in Each
and Changes in FIM Scores Intervention in Relation to Change in FIM Scores
FIM Category Pearson’s r p Occupational Therapy Intervention
and FIM Category Pearson’s r p (2-tailed)
Feeding 2.02 .84
Grooming .10 .19 Cognitive skills
Bathing .11 .12 Comprehension** .23 .003
Upper-extremity dressing* .15 .04 Expression** .23 .003
Lower-extremity dressing .08 .31 Self-care
Toileting .09 .21 UE dressing** .24 .001
Toilet transfer .05 .47 Toilet transfers* .15 .043
Tub transfer .07 .37 Therapeutic activities
Comprehension .13 .08 LE dressing* 2.17 .025
Expression .13 .08 Tub transfers** 2.21 .005
Social interaction .06 .41 Therapeutic exercises
Problem solving .07 .35 UE dressing** .21 .004
Memory** .20 .01 Tub transfers* 2.18 .017

Note. Occupational therapy intensity is determined by dividing the number of
days treated by the length of stay.
*p < .05, two-tailed test. **p < .01, two-tailed test.
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 inde-
pendence 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 re-
lationship to FIM scores. Because research results from
this study did not provide clear evidence for these in-
tervention approaches, our opinion is that more quanti-
tative studies focusing on functional outcomes are
necessary to show the effectiveness of neuromuscular re-
education, group therapy, therapeutic activities, and
therapeutic exercises.
One can also conclude from these results that in-
corporating cognitive skills training into occupational
therapy treatment of patients with MS will lead to im-
proved 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
Note. LE 5 lower extremity; UE 5 upper extremity.
*Significant at p < .05. **Significant at p < .01.
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 interven-
tions. 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 re-
sulted 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 dis-
orders. 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 docu-
mentation procedures, on occasion the total number of
units of occupational therapy treatment was difficult to
decipher. Units of treatment that were unclear in the doc-
umentation were recorded as one unit, respectively. Addi-
tionally, 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

The American Journal of Occupational Therapy 693

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, ex-
amining 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. s
Acknowledgments
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.
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