Effects of multidisciplinary rehabilitation on chronic fatigue in multiple sclerosis: a randomized controlled trial.

BACKGROUND: Several rehabilitation programmes aim at reducing the impact of fatigue in MS patients. Acute and chronic fatigue should require different management. OBJECTIVES: To assess the effects of individually tailored, multidisciplinary outpatient rehabilitation (MDR) on chronic fatigue. METHODS: Forty-eight ambulatory MS patients with chronic fatigue were randomized to MDR or to MS-nurse consultation. Fatigue was assessed by the Checklist Individual Strength (CIS-20R). Secondary outcomes included the Modified Fatigue Impact Scale, Fatigue Severity Scale, Functional Independence Measure, Disability and Impact Profile (DIP), Multiple Sclerosis Impact Scale and the Impact on Participation and Autonomy (IPA). RESULTS: The primary outcome measure CIS-20R overall score showed no significant differences between groups at 12 weeks (P = 0.39) and 24 weeks follow-up (P = 0.14), nor for subscales (t = 12 and t = 24, 0.19≤P≤0.88). No significant within-group effects were found for both groups with respect to the primary (0.57≤p≤0.97) and secondary (0.11≤p≤0.92) outcome measures from baseline to 12 or 24 weeks. CONCLUSION: Multidisciplinary rehabilitation was not more effective in terms of reducing self-reported fatigue in MS patients compared to MS-nurse consultation. Our results suggest that chronic fatigue in patients with MS may be highly invariant over time, irrespective of interventions. TRIAL REGISTRATION: controlled-trials.com ISRCTN05017507.

Client-centred therapy in multiple sclerosis: more intensive diagnostic evaluation and less intensive treatment.

OBJECTIVE: Despite beneficial effects on communication and process measures, client-centred practice has been shown to result in poor functional outcomes. To examine a potential explanation for poor functional outcomes, this paper aims to assess whether in client-centred therapy more time is spent on diagnostic consultation and less time on actual treatment compared to usual care. METHOD: A multicentre cluster randomised controlled trial was performed. Thirteen hospitals and rehabilitation centres, 29 therapists and 269 outpatients with multiple sclerosis participated. Measurements included an inventory of diagnostic and treatment goals, the number of sessions, therapy duration and therapy intensity. RESULTS: In client-centred therapy, more sessions were used for diagnostic consultation (10.9% points difference, p = 0.030); the time needed to formulate the first treatment goal was longer (11.4 days difference, p = 0.041); there was a tendency towards more goals directed to diagnostic issues (0.69 goals difference, p = 0.056), spending more hours on indirect issues (1.16 h difference, p = 0.051) and towards a longer total therapy period (1.56 months difference, p = 0.058) than in usual care. CONCLUSION: Client-centred therapy resulted in more intensive diagnostic evaluation and less intensive treatment. This suggests that client-centred therapy should be adjusted towards a more proportional distribution of time devoted to diagnostic evaluation versus actual treatment.

A cluster randomised controlled trial on the efficacy of client-centred occupational therapy in multiple sclerosis: good process, poor outcome.

PURPOSE: To assess the efficacy of client-centred occupational therapy (OT) according to a client-centred process framework, as compared to usual care OT, in patients with multiple sclerosis (MS). METHOD: A multicentre cluster randomised controlled trial with the institution (i.e. hospital or rehabilitation centre) as the unit of randomisation was performed. A total of 269 outpatients with MS, 13 hospitals and rehabilitation centres and 29 occupational therapists participated. Primary outcomes included measures of disability, participation and autonomy. Secondary outcomes included fatigue, generic health-related quality of life, quality and evaluation of therapy, therapy compliance and therapy frequency. Measurements were taken at baseline, four months and at eight months follow-up. RESULTS: Primary outcome measures did not show significant differences between the two interventions. Secondary outcomes revealed significant differences in favour of the usual care OT on fatigue (physical scale and total scale) and health-related quality of life (bodily pain and vitality) at four months. After eight months only significant differences on mental health were found. Process outcomes (i.e. the information scale of therapy quality and the client-centredness of the organisation) were in favour of the client-centred intervention. CONCLUSION: Because the client-centred intervention resulted in no effects on the primary outcomes and small but negative effects on the secondary functional outcomes, we should seriously reconsider the application of client-centred practice. IMPLICATIONS FOR REHABILITATION: An increasing number of interventions claim to incorporate client-centred practice. Client-centred practice is associated with improved satisfaction but the effects on functional health-related outcomes have not been fully evaluated. The findings of this study show that the process outcomes of therapy were in favour of the client-centred intervention, but no effects were found on the primary outcomes and negative effects on the secondary functional health outcomes. It is suggested that the implementation of client-centred practice should be adjusted in order to achieve optimal health outcomes.

Responsiveness of the Canadian occupational performance measure.

This study evaluated the responsiveness of the Canadian Occupational Performance Measure (COPM), an individualized, client-centered outcome measure for the identification and evaluation of self-perceived occupational performance problems. We recruited 152 consecutive patients with various diagnoses, admitted to the outpatient clinic of two occupational therapy departments, to complete a COPM interview and three self-reported health status questionnaires on two occasions: prior to the start of occupational therapy treatment and 3 months later. The three questionnaires were the Sickness Impact Profile (SIP68), the Disability and Impact Profile (DIP), and the Impact on Participation and Autonomy (IPA). We assessed criterion responsiveness by calculating the area under the curve (AUC) for the receiver operating characteristic curve and the optimal cutoff values for the COPM scores.To determine construct responsiveness, we calculated correlations between the change in COPM scores and the change in the SIP68, DIP, and IPA scores. The AUC ranged from 0.79 to 0.85, and the optimal cut-off values for the performance scores and satisfaction scores ranged from 0.9 to 1.9.We found significant positive correlations between the COPM scores and the SIP68, DIP, and IPA scores. The capability of the COPM to detect changes in perceived occupational performance issues is supported.

Validity of the Canadian Occupational Performance Measure: a client-centred outcome measurement.

OBJECTIVE: To study the convergent and divergent validity of the Canadian Occupational Performance Measure (COPM). DESIGN: Cross-sectional study. SETTING: The occupational therapy departments of two university hospitals in Amsterdam. SUBJECTS: One hundred and five consecutive outpatients. OUTCOME MEASURES: The COPM is a measure of a client's self-perception of occupational performance in the areas of self-care, productivity and leisure. Outcome measures of the COPM are: the client's most important problems in occupational performance and a total score for performance and a total score for satisfaction for these problems. Problems reported in the COPM were compared with the Sickness Impact Profile (SIP68), the Disability and Impact Profile (DIP) and an open-ended question. RESULTS: Complete data were obtained for 99 clients. The identification of occupational performance problems with the COPM surpassed the items reported in the SIP68, the DIP and the open-ended question, which confirms the surplus value of the COPM. Divergent validity was further demonstrated by the low correlation coefficients between the total SIP68 scores and the COPM. Seventy-four per cent of the occupational performance problems reported in the COPM had a corresponding item in the DIP and 49% had a corresponding item in the SIP68. Convergent validity was supported by the fact that 63% of the corresponding problems in the DIP were reported to be a disruption of quality of life and 74% of the corresponding problems in the SIP68 were identified as a disability. CONCLUSION: The results of this study provide supportive evidence for the convergent and divergent validity of the COPM. The data support the assumption that the COPM provides information that cannot be obtained with current standardized instruments to measure health.