Running head: EFFECT OF ENERGY CONSERVATION ON DRESSING 1

Effect of Energy Conservation Strategies on Independent Dressing

Brianna Stemmler

Sacred Heart University

EFFECT OF ENERGY CONSERVATION ON DRESSING 2

Introduction

Multiple sclerosis (MS) is a progressive, demyelinating, neurodegenerative disorder of

the central nervous system (CNS) that primarily affects adults between the ages 15 and 50 (Yu &

Mathiowetz, 2014). One of the most common and debilitating symptoms of the disease is

extreme fatigue that results in a decreased quality of life (QoL) (Motl et al., 2009). The

progression of symptoms, including fatigue, ultimately make it difficult for individuals with MS

to participate in activities of daily living (ADLs) such as dressing. Research suggest that

individuals with MS who utilize energy conservation strategies during completion of tasks

experience better outcomes and an increased QoL (Mathiowetz, Matuska & Murphy, 2001).

Literature Review

Progression of the Disease

MS affects approximately 2.5 million individuals worldwide and is more prevalent in

females than males with a ratio of 5:1 (Harbo, Gold, & Tintor, 2013; Khan, Amatya, & Galea,

2014) The exact cause of MS is unknown but research suggests that environmental triggers or

infectious agents initiate the autoimmune response in individuals who are genetically susceptible

to it (Harbo, et al., 2013). Common symptoms include numbness, muscle weakness or spasms,

optic neuritis, gait imbalance, problems in speech or swallowing, visual impairments, cognitive

impairment, and fatigue (Hwang et al., 2011). The progression of the disease often results in

functional limitations, disability, and decreased QoL (Motl et al., 2009).

The course of MS is categorized into four different types with differing disease

progressions. Relapsing-remitting MS (RRMS) affects 85% of people and is characterized by

clearly defined and unpredictable relapses or exacerbations and episodes of acute worsening of

neurological function (Stultz, 2014, p. 1156). A relapse is defined as an episode of acute CNS
EFFECT OF ENERGY CONSERVATION ON DRESSING 3

deterioration and a remission is defined as partial or complete recovery of symptoms (Miller &

Leary, 2007). Maloni (2013) states that approximately half of the people diagnosed with RRMS

transition to secondary progressive MS (SPMS) within 10 years of the initial diagnosis. SPMS

occurs when relapses decrease in frequency and transition to a slow, steady decline in CNS

functioning (Maloni, 2013). Primary progressive MS (PPMS) is characterized by a steady

progression of the disease from the initial diagnosis without the presence of acute attacks (Miller

& Leary, 2007). Lastly, progressive-relapsing (PRMS) is a progressive deterioration of CNS

function from onset with clear acute relapses with no indication of relapses or remissions (Stultz,

2014).

Quality of Life and other Functional Complications

The progressive and unpredictable symptoms of MS contribute to a reduced QoL for

individuals affected by the disease. The symptoms of the disease make it difficult to engage in

occupational activities and social participation therefore requiring the help of health care

professionals (Yu & Mathiowetz, 2014). Motl et al., (2009) describes QoL as an umbrella term

that encompasses the physical, social, psychological, and spiritual aspects of an individual's

perception of their well being. Factors that contribute to a decreased QoL in MS include: onset of

the disease during the productive years of life, unpredictable and unstable disease course, diffuse

symptoms, extreme fatigue and lack of a cure (Benito-Len et al., 2003).

Amongst the factors previously mentioned that have a negative impact on QoL, fatigue is

an additional variable that impacts the lives of those with MS. Fatigue affects 80% of individuals

with MS and it is reported to be one of the most debilitating symptoms of the disease (Blikman,

et al., 2013). Fatigue in MS, known as MS-related fatigue, is an unusual or abnormal form of

fatigue that differs from the fatigue experienced by healthy individuals after exertion (Bakski,
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2003, p. 219). MS-related fatigue limits energy and endurance therefore making it difficult for

individuals to engage in their occupations. As the symptoms of MS progress, the ability to

engage in ADLs becomes increasingly challenging as a result of MS-related fatigue (Mansson &

Lexell, 2004). A study done by Mansson and Lexell (2004) found that 177 out of 248 individuals

with MS reported having difficulties during independent dressing.

Occupational Therapys Role in Implementing Energy Conservation Strategies

Occupational therapy (OT) interventions for people with MS aim to promote

independence and engagement in occupations (Yu & Mathiowetz, 2014). Energy conservation

strategies are implemented by OTs as activity modifications that help reduce fatigue during the

completion of dressing (Blikman et al., 2013). Common strategies include: balancing work and

rest, verbalizing personal needs, delegating activities, modifying priorities, using efficient body

mechanics, organizing work spaces, taking seated breaks, and the use of assistive technology

(Blikman et al., 2013). OTs educate and encourage individuals with MS to use energy

conservation strategies so energy expulsion becomes more resourceful (Jaln et al., 2013). A

study completed by Mathiowetz, Matuska & Murphy (2001) concluded that community based

energy conservation courses taught by OTs had a positive impact on fatigue management for

people with MS. Additional research reported that 80% of participants with MS in their study

reported using energy conservation strategies during the completion of dressing and experienced

increased feelings of self efficacy (McLaughlin & Zeeberg, 1993).

Methods

Subjects

There will be three 35-year-old Caucasian females diagnosed with MS. The subjects are

in an acute inpatient rehabilitation program at Middlesex hospital. The subjects will report
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experiencing fatigue during independent dressing of the upper and lower extremities. The subject

will be independent with functional mobility and demonstrate no major sensory impairments,

such as blindness or deafness. The subjects will be English speaking and have the ability to

understand what independent dressing entails and how energy conservation strategies can be

used to decrease fatigue. Female subjects with MS will be excluded if they are dependent with

dressing and/or functional mobility or if they have comorbidities that are more dominant than the

symptoms of MS. Also, female subjects will be excluded if exacerbations occur more frequently

than periods of remission.

Settings and Materials

All baseline and intervention sessions will occur in the inpatient OT rehabilitation room

at Middlesex hospital. All sessions will occur at approximately 10:00 AM. Tools needed for the

intervention will be provided by the examiner. The tools will include a chair, sweatpants, a pair

of socks, and a t-shirt.

Design

The study will use a multiple baseline design. A multiple baseline design was chosen so

the implementation of the intervention could be staggered and suggest that improvements in

dressing were due to the intervention, and not environmental or other effects. The IV is energy

conservation strategies and the DV engagement in independent dressing, of which there will be

three outcome measures. Once energy conservation strategies are implemented, they can not be

completely removed as they are a learned behavior. To quantify the outcome measures, the

subjects will be scored using the Functional Independence Measure (FIM).

Procedures
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Baseline sessions will be different for each subject. The examiner will collect baseline

data for subject 1 everyday for 6 days, subject 2 everyday for 12 days, and subject 3 everyday for

18 days. During baseline data collection, the subjects will independently don their sweatpants,

socks, and a t-shirt and the examiner will assess and score them using the FIM. Baseline data

collection will occur in the inpatient OT rehabilitation room at Middlesex hospital. All sessions

will occur at 10:00 AM. Subjects will be given up to 30 minutes to don their sweatpants, socks,

and a t-shirt. The examiner will administer the baseline sessions and will collect all of the data

via videotape. All subjects were asked to wear a pair of shorts so the donning of sweatpants can

be done over the shorts.

Intervention

There will be a staggered implementation of the energy conservation strategies. The

examiner will implement the energy conservation strategies to subject 1 on day 7, subject 2 on

day 13, and subject 3 on day 19. The staggered intervention will begin with an occupational

therapist coming to each session and educating the subjects on various energy conservation

strategies. Prior to the intervention session, the occupational therapist will attend a training

course to learn how to educate clients on energy conservation strategies. The energy conservation

strategies will include: taking seated breaks when fatigued, adaptive equipment (reacher and a

sock aid), dressing their lower body before their upper body, and pursed lip breathing. The

subjects will be instructed by the occupational therapist to utilize the learned energy conservation

strategies during dressing. Then, the occupational therapist will leave and the examiner will enter

the room. During the intervention, the subjects will use energy conservation strategies and

independently don their sweatpants, socks, and a t-shirt. Subjects will be given up to 30 minutes

to don their sweatpants, socks, and a t-shirt. The examiner will administer the intervention
 EFFECT OF ENERGY CONSERVATION ON DRESSING 7

sessions and will collect all of the data via videotape. All subjects were asked to wear a pair of

shorts so donning of sweatpants can be done over their shorts. The intervention data collection

will occur in the inpatient OT rehabilitation room at Middlesex hospital. All sessions will occur

at approximately 10:00 AM.

Outcome Measures

The outcome measures of the DV will include donning sweatpants, socks, and a t-shirt

These will be defined as follows:

Donning sweatpants: Participant is able sit down and pull sweatpants over the right and left foot,

stand up, and pull sweatpants up over their hips. Examples will include putting the sweatpants on

the correct way, completely and independently. Non examples include if the participant does not

have the sweatpants on completely, has the sweatpants on backwards or inside out, or asks for

assistance during the task.

Donning a pair of socks: Participant is able to sit down putting one sock on each foot. Examples

include pulling each sock completely and independently over the heel and ankle of the foot and

have the sock facing the correct way. Non examples include if the participant does not have both

socks on, has a sock(s) on facing the wrong way, the sock(s) is not pulled up over the heel or

they ask for assistance during the task.

Donning a t-shirt: Participant is able to sit down and pull their shirt over the right and left arms

and their neck, and pull it down to an appropriate length near the waist. Examples include that

shirt is put on completely and independently, and facing the correct way. Non examples include

if the participant does not have the shirt on, has the shirt on backwards or inside out, the shirt is

not pulled down to their waist or they ask for assistance during the task.
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Each behavior will be measured with event recording during the entire dressing task to

determine the level of independence each subject has during dressing.

Baseline and intervention sessions will be coded by the rater who is blind to the purpose

of the study and the diagnoses of the participants. The rater is trained in administering and

scoring the FIM. To score the subjects, the rater will watch the videotaped baseline and

intervention sessions and determine their level of independence during dressing.

Graphing of each dependent variable for each subject will be used for visual analysis of

the outcome measure data. The diagram shown in Appendix A shows graphing for one of the

dependent variables. It is hypothesized that the staggered implantation of the intervention will

lead to increases in the outcome measures of the DV.

IOA

All sessions will be videotaped and 30% of all the tapes will be assessed for IOA on all

three outcome measures. IOA will be examined during all of the baseline and treatment phases.

Inter-observer agreement will be established by having a second rater code 40% of the

videotapes previously coded by the first rater. Both raters will be trained to reach 90% IOA on

sample videotapes that are not included in this study. Both raters are OTs that work in hospital

settings, are trained to administer and score the FIM, and they will be trained on coding prior to

the start of this study.

Treatment Fidelity

The intervention of energy conservation strategies will be observed for treatment fidelity

in 30% of the videotaped intervention sessions. The subjects will be examined based on their
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ability to independently don sweatpants, socks, and a shirt using energy conservation strategies.

The primary researcher will check everyday to ensure that the examiner is teaching and

suggesting the use of the energy conservation strategies.

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Figure 1
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