Occt 643 - Cat Evidence Table

\
School
of Occupational Therapy
Touro University Nevada
OCCT 643 Systematic Reviews in Occupational Therapy
Critically Appraised Topic Project
]/
EVIDENCE TABLE
Name: Talia Bartolotta and Michelle Wilson
Date: October 8th, 2015
Does telehealth improve quality of life through adherence to interventions for individuals diagnosed with neurodegenerative diseases?
Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Inclusion criteria: published after 2008, 13 years and older, intervention of telehealth, diagnosis of neurodegenerative disease, English
Exclusion criteria: published before 2008, 13 years or younger, any intervention other than telehealth, CVA or physical disabilities, languages other
than English, qualitative studies
Author/
Year
(Jelcic et al.,
2014)
Study Objectives
Level/Design/ Subjects
Examine feasibility
& efficacy of using
cognitive
assessments &
treatment through
telerehabilitation to
patients diagnosed
with Alzheimers
Disease (AD)
Level I; RCT
27 patients diagnosed
with AD according to
National Institute of
Neurological and
Communicative
Disorders & Stroke
Clinical dementia
score 0.5-1
Exclusion: not on antidementia drugs, not
have any brain lesions
Intervention and
Outcome Measures
Intervention:
2 weekly 1 hr.
session over 3-month
period
3 groups; 1 at adult
day center receiving
telerehabilitation; 1
at San Camillo
Hospital in Venice
receiving in-patient
& telerehabilitation
services
Exercises focused on
interpretation of
Results
Episodic memory
(p=0.3) & cognition
(p=0.03)
86% patients
receiving
telerehabilitation
reported 10 for
satisfaction
Statistically
significant increase in
quality of life (QOL)
in individuals
receiving telerehabilitation.
Study
Limitations
No
limitations
provided
Implications for OT
Clinical & communitybased practice of OT:

telerehabilitation may
lead to improvements in
episodic memory
therefore increasing
engagement in social
participation and QOL
Program development:
telerehabilitation can be
just as effective as in-face
treatment for individuals
suffering cognitive and
language impairments
written words,
sentences, stories
Control group
completed exercises,
practiced manual
skills fostering
creativity and
improved verbal
communication
Outcome Measures:
Mini Mental State
Exam, Verbal
Naming Test, Brief
Story Recall, Rey
Auditory Verbal
Learning Test
(Dorsey et al.,
2013)
Determine
feasibility,
effectiveness, and
economic benefits
using web-based
telemedicine to
provide care to
individuals
diagnosed with
Level I, RCT
20 subjects diagnosed
with PD recruited from
University of
Rochester & Johns
Hopkins
Men/women 30+ years
old
Inclusion: required to
have internet access in
Intervention:
Treatment group: 9
participants, control
group: 11
7 month program
Treatment group
received 3 visits over
teleconference over
7 months
Not large enough to

show statistical
significance
Feasibility: greater
adherence to
treatment session
attendance via
telemedicine (93%)
versus in-person
(91%)
Small
sample size
Unable to
demonstrate
statistical
significance
Societal needs:
telerehabilitation can
improve cognitive
functioning for elderly
patients with cognitive
impairments as a result of
neurodegenerative
diseases
Healthcare delivery &
policy: Although results
show improvements in
cognitive functioning in
AD, it is unknown where
funding will be coming
from
Education & training of
OT students: more
education for OT students
needs to be incorporated
in curriculum to increase
use of telerehabilitation in
practice
Refinement, revision, &
advancement of factual
knowledge or theory:
more research needs to be
done with additional
neurodegenerative
diseases to generalize
results
Increased attendance to
telemedicine sessions
yields greater positive
outcomes
Creating a telemedicine
program for individuals
diagnosed with PD will
Parkinsons disease
(PD) in their homes
home, live in New

York or Maryland
Control group: 3 inperson clinical visits

Intervention
provided was the
same for treatment
and control group
Treatment provided
at month 1, 4, and 7
Outcome Measures:
Parkinsons Disease
Questionnaire,
Unified Parkinsons
Disease Rating Scale
Parts 1-3, Montreal
Cognitive
Assessment, Patient
Assessment of Care
for Chronic
Conditions (PACIC)
Economic value:
statistical significant
difference in travel
time; 53 minutes vs.
255, demonstrating
feasibility and
effectiveness of
telemedicine
(Paul et al.,
2014)
Explore the
effectiveness and
participant
experience of webbased
physiotherapy for
individuals
moderately
affected by
multiple sclerosis
(MS)
Level I, RCT
30 participants,
Intervention group, 15;
control group, 15 (12
females, 3 males in
each group)
No difference in age,
BMI, time since
diagnosis, or expanded
disability status score
between groups
Intervention:
2 times per week for
12 weeks
2 groups,
intervention received
12 weeks of
individualized webbased exercise
Control received
regular care and
general advice
towards exercising
Improvement in gait
speed (p=1.07)
Intervention group:
statistically
significant
improvement in
physical subscale of
MS Impact Scale
(p=0.48)
Control group:
statistical significant
Small
sample size
Short
intervention
period
increase adherence to
therapy sessions & reduce
economic burden
Societal needs: patients
diagnosed with
progressive
neurodegenerative
diseases benefit from
receiving therapy in their
homes
policy: providing
telemedicine reduced
economic burden and
increased feasibility
OT students: OTs need
to be educated on how to
deliver telemedicine
therapy when working
with patients diagnosed
with progressive diseases
larger samples need to be
used to identify whether
telemedicine is beneficial
Perceived improvement in
health and well-being was
found through web-based
physiotherapy
providing web-based
physiotherapy increases
confidence regarding
physical activity and gait
(Asano,
Preissner,
Duffy, Meixell
& Finlayson,
2015)
Analyze and
promote goal
setting to modify
behavior change
via teleconference
for individuals
diagnosed with MS
Inclusion: All patients

diagnosed with
moderate MS,
recruited from MS
Service in Scotland,
score of 5-6.5 on
Expanded Disability
Status Score, stable on
medication for 30
days, no relapses
within the last 3
months, no
cardiac/pulmonary
conditions
Level II, Cohort

81 participants
recruited from
National MS Society
Mean age: 57.4,
majority were women
improvement in
anxiety (p=0.16)
Intervention group:
web-based program
with questions on the
computer screen,
each exercise had 4
levels of difficulty
and every work out
began with a warm
up and ended with
cool down. Work
outs logged by
participants and
physiotherapist
assessed each work
out, discussed
progress, and
updated program as
needed
Outcome Measures:
25 Foot Walk Test,
Berg Balance Scale,
Timed Up-and-Go,
Multiple Sclerosis
Impact Scale, Leeds
Multiple Sclerosis
Quality of Life
Scale, Multiple
Sclerosis Related
Symptom Check
List, Hospital
Anxiety and
Depression Scale
Intervention:
6 week Fatigue
Management
Program
Weekly 70 minute
group (4-7
participants) based
53.5% of rated goals

were considered
achieved
Mean goal
achievement score
was 7.0 (SD=3.1)
Small
sample size
Poorly
randomized,
those
participants
who
speed to those diagnosed

with moderate MS.
Societal needs: patients
with moderate MS
improve well-being
through web-based
physiotherapy
policy: web-based
physiotherapy is a
feasible method for those
diagnosed with moderate
MS
OT students: more
education on
physiotherapy in clinics
and web-based needs to
be included in curriculum
More research regarding
this topic needs to be
done due to results not
being statistically
significant

OT practitioners need to
focus on application of
fatigue management
strategies to IADLs rather
than ADLs
experiencing
extreme fatigue
(Golomb et al.,
2010)
Investigate whether
in-home remotely
Inclusion: 18+ years

old, score of > 4 on
Fatigue Severity Scale,
no severe cognitive
impairments
determined by Blessed
Orientation-MemoryConcentration Test
Level III, before and

after
teleconference phone
calls, facilitated by
OT
Taught 14 energy
management
strategies over 6
week sessions
Addressed fatigue,
communication
skills, energy
conservation,
prioritize activities
for energy purposes,
planning days to
manage fatigue to
live balanced life,
incorporate change
into life and setting
goals
Last session, patient
asked to complete
short term (2-3
weeks), intermediate
(3 months), and long
term goal (6
months), 2 goals per
timeline
Outcome Measures:
Likert scale utilized
to assess goal
achievement
1-Have not started
working on goal
10-Achieved goal
Intervention:
IADLs and leisure

had two highest mean
goal achievement (7.4
and 7.9)
Education and
uncodeable goals had
lower scores (5.8 and
4.3)
Short term goals more
likely to be achieved
(66.3%) than
intermediate (47.5%)
or long-term (43.6%)
responded
first were
placed in the
first group
rather than
dealyed
Effects of
mindfulness
training on
attention
were only
subjectively
investigated
Participant #3 had
lower scores than #1
Gloves were
too sensitive
Creating programs
focused on self-goal
setting support positive
intervention effects on
self-reported MS fatigue,
QOL, and use of fatigue
management strategies
Societal needs: providing
therapy through
teleconference on goalsetting to patients with
severe fatigue is shown to
be effective in increasing
QOL & energy levels
policy: improved QOL
can further reduce health
care costs
OT students: OT
practitioners need to be
educated on how to
develop mechanisms that
would enable long-term
follow up and periodic
support for clients
Poorly randomized,
results are not
generalizable to all
populations; mindfulness
only subjectively
investigated, need to
create way to objectively
measure results
monitored virtual
reality videogamebased
telerehabilitation in
adolescents with
hemiplegic cerebral
palsy (CP) can
improve hand
function and
forearm bone
health and
demonstrate
alterations in motor
circuitry activation.
(Settle et al.,
2015)
Identify a way to
increase adherence
to medication
management for
3 adolescents
Inclusion: severe right
side hemiplegic CP,
upper body affected
more than lower body
2 male (subject #1 and
#3), 1 female (subject
#2)
Ages 13, 15, 15
Both males had
perinatal strokes,
female had
intraventricular
hemorrhage
Received botox for
spasticity
Level I, RCT
Two groups: control
and treatment control
received routine care
and treatment received
3 months, 30
minutes per day for 5
days/week with
plegic hand
Videogame system
included 5DT 5
Ultra glove and
PlayStation 3
Networked into 2
difference hospitals
Gloves have
fiberoptic sensors in
each finger
All games required
finger
flexion/extension
and thumb
movement
Followed
instructions provided
on screen and
awarded points
based upon accuracy
Outcome Measures:
Sammons Preston
Jamar dynamometer
and pinchometer (pre
and post), Bruininks
Oseretsky Test of
Motor Proficiency,
Jebson Hand
Function Test, DXA
and pQCT
Intervention:
Control group:
routine care
Treatment group:
MS home automated
and #2, may be due to

an error in videogame
system causing him to
stop intervention at
day 36 and start again
once fixed
Jebson Hand Function
Test: significant
improvements in all 3
participants
Improvements in
ROM, Subject #1: 4
finger improvement,
Subject #2 and #3:
improvements in 3
fingers
DXA: baseline score
was less in plegic arm
than non-plegic arm;
#1 & #2 gained bone
mineral content
fMRI: stastically
significant changes in
spatial firing
Small
sample size
Technical
issues with
participant
#3
Obtaining
motivation
was difficult
Not enough
outcome
measures
Using a 95%
confidence interval:
p< .05
Small
sample size
Short
intervention
period
Adolescents lose coverage

of services at a certain
age; providing in-home
therapy increases access
to care
Videogame rehabilitation
for adolescents with CP
can improve hand
function and bone health
Societal needs: Those
unable to seek therapy in
a clinic can still show
gains inside their home in
the natural setting
policy: Improvements in
function at a basic ROM
level makes adolescents
more independent,
reducing need for
extensive therapy
OT students: Training in
various technology that
may be utilized with this
population; adolescent
health care & transitional
services
Need to develop more
functional technology for
more accurate results
Using memory aids and
slowly withdrawing them
those diagnosed
with MS
routine care and

telemedicine
Recruited from MS
clinic
Inclusion: MS, taking
INFbeta-1a IM and
vitamin D
Exclusion: on other
medication, in support
group, had
exacerbation in last 2
months
30 participants total,
13 in control group, 17
in treatment average
47 average age
telehealth system
(MS HAT)
1 neurologist and 1
nurse practitioner
provided care to
patients; MS
specialists
MSHAT group
received daily email
or text reminder to
administer INFbeta1a IM
Logged when they
took Vitamin D
Times and which
type of message sent
were dependent upon
patient to ensure
client-centeredness
Both control and
treatment group kept
a calendar and
placed all medication
syringes into specific
medication container
3 month visit asked
participants how
often they were
refilling
prescriptions and
completed the
PDDS.
All but one
participants
completed in-person
visit
Outcome measure:
Pre-test: each
participant
underwent thorough
Syringe count and

MMAS-8, positive
correlation (p=.002)
Alert rates from
MSHAT group and
syringe count
(p=.026)
Vitamin D intake
adherence did not
change for the
telehealth group but
increased for those in
the routine care group
that lived alone
Slight
cognitive
impairments
in many
participants
increased adherence to
medication
MMAS-8 is an easily
utilized tool to use with
patients diagnosed with
MS in regards to
medication adherence and
easily detects those who
are not adhering to their
medication
Societal needs: Memory
aids were effective in
those diagnosed with MS
suffering from cognitive
deficits to adhere to their
medication
policy: Telemedicine is a
time & money saver. All
patients medical
information found in one
location.
OT students: Need to
include more education
on telemedicine and sideeffects of medications
regarding physical and
cognitive functioning in
curriculum
Need to increase sample
size and intervention time
to generalize results.
Needs to be used on a
wider range of MS
diagnoses
(Finlayson,
Preissner, Cho,
& Plow, 2011)
Identify the
effectiveness of
teleconference
fatigue
management for
people with
multiple sclerosis
Level I; RCT
Two groups: waitlist
control group and
treatment group
receiving fatigue
management via
teleconference
randomization through
permuted block design
190 participants total,
90 in intervention
group, 96 on wait list
neurological exam
(Expanded Disability
Status Scale utilized)
3 month visit:
participated in either
telemedicine visit,
phone, or in person,
whichever was most
convenient
6 month visit: turned
in calendar,
completed blood test
for vitamin D,
completed PDDS
and MMAS-8
Expanded Disability
Status Scale, Patient
Determined Disease
Steps (PDDS),
Morisky Medical
Adhere Scale
(MMAS-8), Symbol
Digit Modalities Test
(SDMT), 25-OH
Vitamin D Blood
Panel Test
Intervention:
Treatment consisted
of 6 week group
based intervention.
Sessions were once
per week for 70
minutes. Group
based interventions
were facilitated by a
licensed OT,
sessions covered a
variety of topics on
fatigue some of
Significant reduction
in three FIS subscales
Significant
improvement in SF36 on the role
physical subscale
No statistical
significance with the
rest of the SF-36
subscales, FSS, or
self-efficacy measure
Two subscales of the
HRQOL
All
measures
were selfreport

Fatigue management
intervention facilitated by
OTs demonstrates strong
support for the viability of
teleconference-delivered
intervention based on
fatigue management for
individuals diagnosed
with MS
Fatigue Management
Received treatment:
each group had 5-7
participants
Inclusion: Illinois
resident, MS, at least
18 yrs., functional
health literacy, and a
weighted score of >12
Blessed Orientation
Memory Concentration
Test
Sample size justified
with Power of FIS
physical subscale
effect size
which focused on
communication,
management,
compensatory
strategies, and
energy conservation
Outcome measure:
Post-test: outcome
measures given
directly after the 6
week intervention.
6 month follow up
using the same
outcome measures
Fatigue Impact
Scale, FSS, SF-36,
Self-Efficacy for
Energy Conservation
Questionnaire
demonstrated
significantly greater
improvements on role
physical and social
All subscales
demonstrated some
improvement, even
after 6 months of
intervention.
Using a 95%
p< .10
FIS: Cognitive
subscale p=.0013,
physical subscale
p=.0144, and social
subscale p=.0021.
SF-36: Role physical
p=.0002
(Fincher,
Ward,
Dawkins,
Magee, &
Willson, 2009)
To determine the
usefulness of
telehealth
medication
counseling for
Parkinsons
disease.
Level I; RCT
3 groups - 25
participants each
Group 1: received
treatment in person
Group 2: received
treatment over
telephone
Group 3: received
treatment via telehealth
(video phone)
Veterans, diagnosis of
PD, recruited from
Intervention:
Patients provided
with materials on
medication
published by
National Parkinsons
Foundation
During each session,
the patients
understanding of
medication
regimens, schedules,
rationale, side
effects, and self-
Overall, participants
were more satisfied
with the video phone
than the telephone.
The mean NPTQ
were not statistically
significant between
telephone and video
phone.
p< .05
PPTQ: statistically
significant p=.004
Majority of
participants
being male
and
Caucasian
Programs reduce fatigue

impact but not fatigue
severity
Societal needs:
teleconference can
significantly benefit those
diagnosed with MS who
are homebound
policy: Managing Fatigue
Program is just as
effective through
teleconference as it is
face-to-face
OT students: Need to
include more education
on telehealth to OT
students
Include more objective
measurements to make
results more statistically
significant
Telehealth is successful
for those with movement
disorders and tremors
Videophone more
effective for telehealth
than regular phone more
improvements with
videophone
Societal needs: Nurses
feel that through video
phone they are able to
(Dobkin et al.,
2011)
Examined the
feasibility and
effectiveness of
telephone based
CBT for
individuals
struggling with
depression who are
diagnosed with PD
PADRECC at the
MEDVAMC in
Houston
Inclusion:
primary/secondary
diagnosis of PD,
taking 3 meds for PD,
independent in
medication
management, landline
at home, able to use
phone or telehealth
system
Average age was
70.18, most Caucasian,
47 men, 2 women
Diagnosed with PD for
an average of 5.5 years
management
strategies were
addressed
Outcome measure:
After 14 days of
enrollment, all
participants
participated in 20-30
minute standardized
PD medication
counseling session
PD Quality of Life
(PDQ-39), Patient
Post Telehealth
Questionnaire
(PPTQ), Nurse Post
Telehealth
Questionnaire
(NPTQ)
Level III; cohort

Participants completed
a randomized research
study prior to this one
that looked at the
effectiveness of faceto-face CBT
intervention
8 male; 13 female
20 white, 1 black
Participants recruited
through the Richard E.
Heikkila Movement
Intervention:
CBT over phone for
10 wks 1
session/wk for 60-90
mins
Sessions included
behavioral
activation,
recommendations to
gradually increase
exercise, monitoring
and restructuring
thoughts, relaxation,
Changes in mood or
emotions: p=.036
Changes in physical
functioning: p=.004
Self-management
constipation: p=.002
Self-management
meals and sleep:
p=.035
Satisfied with
telehealth visit:
p=.005
Satisfaction with
nurses instruction:
p=.009
NPTQ:
Taking medication as
prescribed: p=.036
Correct amount and
schedule: p=.014
Medication side
effects: p=.031
New or worsening PD
symptoms: p=.029
Changes in physical
function: p=.038
QOL, problemfocused coping, sleep,
social support, and
caregiver burden all
did not show
significant change
over the course of the
study.
No increase in quality
of life for the
telemedicine group as
well as the face-toface group.
Small
sample size
Uncontrolle
d pilot
design
Motor
changes
could not be
assessed due
to the
absence of
in-person
assessment
check in with patients

more frequently leading
to better adherence of
medication protocols.
policy: Providing
medication management
strategies to individuals
diagnosed with PD via
video phone is just as
effective as providing
intervention over the
phone or in person
OT students: Providing
more education in
curriculum of medication
management programs
Include OT in medication
management process

Including and educating
caregivers on cognitive
behavioral strategies can
show increased adherence
to interventions
Telephone administered
CBT was associated with
significant improvements
in depression, anxiety,
Disorders Clinic at
Robert Wood Johnson
Medical School and
the American
Parkinsons Disease
Association.
Participants required to
enroll with a family
member.
Inclusion criteria:
diagnosed with
Parkinsons and
depression, clinical
global impression
severity scale score of
> 4. Had to be between
ages of 35-85 and
stable with medication
for at least 6-8 weeks.
worry control, and

sleep hygiene with
anxiety management
being emphasized
the most.
Caregivers could
receive up to 4
separate educational
sessions, 30-60
minutes each.
Provided in order to
assist caregiver in
making sure loved
one was
implementing CBT
strategies that they
were learning.
Therapy
administered by one
of the authors of the
study, one person
with post-doctoral
education, and two
master level
clinicians with
background and
training in CBT. All
individuals had
experience treating
patients with PD and
had completed
phone-based therapy
before.
Pts received session
by session manual
discussing strategies,
practice examples of
everything being
taught, and blank
worksheets to record
Set at p< .01

HAMD: scores
dropped from severe
to mild range at pre to
post tests.
Depression: (P<.001)
Anxiety: (P<.001)
Negative Thoughts
(P=.01)
Coping (P=.001)
Long term
benefits
could not be
assessed
because the
only post
treatment
was done
one month
after and
nothing else
was looked
at following
that time
period
Results may
not be
generalizabl
e due to
more
advanced
PD, those
without
social
support,
severe
depression.
coping, and negative

thoughts
Societal needs:
Telehealth may provide
an adequate psychosocial
approach for patients
diagnosed with
Parkinsons struggling
with depression
policy: Telehealth can
potentially result in less
psychiatric and medical
comorbidity, fewer past
trials of antidepressant
medications but they had
higher rates of current
antidepressant medication
OT students: Include
more opportunities for
caregiver education on
implementation of
cognitive behavioral
strategies
Implement a more
accurate way to measure
motor changes in those
with PD through
telemedicine
CBT practice.
Outcome measures:
All outcomes
reassessed at weeks
5, 10, and 14
Hamilton Depressing
Rating Scale, Beck
Depression
Inventory, Inference
Questionnarie IQ,
Medical Outcomes
Short Form (SF-36),
Brief Cope, Social
Feedback
Questionnaire,
Pittsburg Sleep
Quality Index,
Caregiver Distress
Scale (CDS), Burns
Empathy and
Helpfulness Scale
(Zissman,
Lejbkowicz,
Miller, 2012)
To assess the
benefits of short
term
implementation
telecare for
patients
diagnosed with
MS using the
Clinical Value
Compass
Level I; RCT
Designed to assess
health-related QOL in
regards to cost and
benefits of medical
costs using
telemedicine
Carmel Medical
Center in Israel
Inclusion: diagnosis of
MS, relapsingremitting, speak
Hebrew, 18+ years old
Exclusion: no
secondary disease,
fully cognitively
functioning
Intervention:
Pts had access to
telemedicine system
24 hrs/day, 7
days/wk for 6
months
Outcome Measures:
First 6 months: data
collected from the
Expanded Disability
Status Scale
Intervention: next 6
months
Outcomes measured
by: Number of
relapses and which
stage they occurred
in, changes in scores
Using a 95%
p< .05
Barthel Index:
Mean=88.4
EDSS: significant
increases in EDSS in
both treatment and
control group, lower
deterioration amongst
telemedicine group
following pre and
post interventions
Treatment group:
decrease in 6 MS
related symptoms
Control group:
decrease in 5 MS
No
limitations
provided

Utilizing telemedicine
with MS does not cause
any harm, increases
quality of life, and
decreases health related
costs and MS related
symptoms
The Health Value
Compass is an effective
measurement tool
Societal needs: providing
telecare to those
diagnosed with MS may
34 of the 40
participants were
women
Mean age = 43.8
All participants had
been diagnosed with
MS for an average of 7
years
2 groups with 20
participants in each;
control received only
treatment in clinic and
treatment received
telemedicine and
treatment in clinic
of EDSS, and the

severity of MS
symptoms described
by the patient.
Collected by
telephone every
other month.
Expanded Disability
Status Scale (EDSS)
HRQoL
MSQoL54
Barthel Index
CLALIT Health
Services
related symptoms
HRQoL: telemedicine
group showed a
positive change in 6
categories, control
group showed
positive change in 2
categories
decrease relapses and

increase QOL
policy: Telemedicine can
significantly decrease
costs of healthcare
(p=.046)
OT students: More
education regarding
outcome measures used
with MS (i.e. Health
Value Compass)
Controlling for
cointervention during
studies. Ensure treatment
group is only receiving
telehealth, not in
conjunction with inperson care to validate
benefits of telehealth

Occt 643 - Cat Evidence Table

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Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

Date: October 8th, 2015

Clinical & communitybased practice of OT:

Not large enough to

home, live in New

Control group: 3 inperson clinical visits

Inclusion: All patients

Level II, Cohort

53.5% of rated goals

speed to those diagnosed

Clinical & communitybased practice of OT:

Inclusion: 18+ years

Level III, before and

IADLs and leisure

and #2, may be due to

Adolescents lose coverage

routine care and

Syringe count and

Clinical & communitybased practice of OT:

Programs reduce fatigue

Level III; cohort

check in with patients

Clinical & communitybased practice of OT:

worry control, and

Set at p< .01

coping, and negative

Clinical & communitybased practice of OT:

of EDSS, and the

decrease relapses and

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