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Feasibility, Reliability, and Convergent Validity of the Five Times Sit-to-Stand Test via Telehealth in Multiple Sclerosis

The effectiveness of occupational therapy (OT) services for people with multiple sclerosis (MS) has not been updated since the last systematic review in 2010, particularly outcomes within the scope of OT practice. The objective of this systematic review was to appraise evidence published since 2011 on the effectiveness of interventions within the scope of OT practice for activities of daily living (ADL) and sleep in adults with MS.

Quantitative studies (Oxford Centre for Evidence-Based Medicine Levels of Evidence 1b through 3b) from January 2011 through July 2023 were systematically reviewed through 3 literature searches performed in January 2019, February 2022, and July 2023 using the Medline, APA PsycInfo, Cumulative Index to Nursing and Allied Health Literature, OTseeker, and Cochrane Database of Systematic Reviews. Inclusion criteria were adult participants with MS and OT-related interventions that addressed ADL or sleep. All authors independently screened titles and abstracts and then appraised full-text articles. Then at least 2 authors analyzed and grouped included articles into outcomes of interest. Risk of bias for study quality and strength of evidence were then analyzed.

The review included 45 studies on sleep, falls and functional mobility, toileting hygiene (continence), sexual activity, and general ADL. Cognitive behavioral therapy, mindfulness training, targeted exercise programs, and counseling using the Permission, Limited Information, Specific Suggestions, and Intensive Therapy model or the Good Enough Sex model were effective in adults with MS.

Occupational therapists can provide interventions using the above approaches, which have been shown to empirically improve ADL function and sleep outcomes. Researchers, consumers, and practitioners should consider demographic and diagnostic differences when generalizing these findings.

We thank Deborah Lieberman, Elizabeth G. Hunter, Susan Cahill, and Hillary Richardson at the American Occupational Therapy Association for their support during this project. We also thank University of Puget Sound science librarian Eli Gandour-Rood for conducting the first literature search update.

The authors have no conflicts of interest to report.

The systematic review was originally supported by the American Occupational Therapy Association. 

Multiple sclerosis (MS) is a progressive disease of the central nervous system that profoundly affects engagement in activities of daily living (ADL) and sleep. The Multiple Sclerosis International Federation reported that the most common MS symptoms include fatigue, pain, sexual dysfunction, problems in movement and coordination, bladder and bowel function, vision, as well as cognitive and emotional changes.

 Due to the complexity of MS, a multidisciplinary care team is recommended for MS care. Occupational therapists contribute to the multidisciplinary team in goal setting and functional training.

 Depending on the needs of individuals with MS, occupational therapists use the approaches of promoting, establishing/restoring, maintaining, and modifying performance and participation in ADL and sleep, and/or preventing loss of the ability to perform ADL or to sleep well, to optimize patients’ occupational performance.

Occupational therapists employ occupation-based interventions within the scope of practice. According to the Occupational Therapy Practice Framework-4 (OTPF-4),

 occupations are categorized as ADL, instrumental ADL, health management, rest and sleep, education, work, play, leisure, and social participation. The ADL category is divided into the subcategories of functional mobility, toileting hygiene (continence), sexual activity, dressing, bathing/showering, personal hygiene/grooming, and eating/feeding.

 The rest and sleep category is further subdivided into rest, sleep preparation, and sleep participation.

 Given the impact of MS on ADL and sleep, occupational therapy (OT) offers benefits to people with MS.

In their 2014 systematic review of OT interventions for people with MS, Yu and Mathiowetz

 found strong evidence for fatigue management courses, moderate evidence for inpatient and outpatient rehabilitation service effectiveness, and limited evidence for health promotion programs. Their findings substantively contributed to health care professionals’ portfolio of OT interventions for individuals with MS. And yet, a comprehensive examination of the scope of OT practice in specific outcomes, rather than a broad range of outcomes, would reinforce the role of OT among peer health care professionals. Further, since the review was completed, more focus has been placed on the specific outcomes of sleep and ADL (including avoiding falls, toileting hygiene/continence, and sexual activity) affecting the quality of life of individuals with MS, as indicated in recent publications.

 MS care teams would benefit from an appraisal of recently published empirical evidence for the effectiveness of OT interventions addressing these outcome areas. Thus, the purpose of this systematic review is to determine the evidence for the effectiveness of interventions within the scope of OT practice to improve and/or maintain performance and participation in ADL and sleep for adults with MS and to inform new practice guidelines for occupational therapists in MS care.

This systematic review was 1 of 4 projects collectively covering areas of occupation, as defined by the OTPF-3 (official version at the time the projects began),

 updating evidence from the previous review.

 We followed the Cochrane Review methodology

 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

 No individuals with MS or members of the public were involved in the review process. A medical librarian conducted the original review by searching the Medline, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, OTseeker, and Cochrane Database of Systematic Reviews for articles from the years 2011 through 2019. Results were collated and duplicates removed. The project methodologist reviewed the citations and eliminated irrelevant articles (eg, wrong year or population). After a delay due to the COVID-19 pandemic, an update of the search was conducted in February 2022 by a university science liaison librarian, using the same criteria as in the first search, and in July 2023 by the third author (G.S.T.), using the topics identified as relevant in the earlier searches.

Search terms were created with input from an advisory group of clinical and quality improvement content experts, the research methodologist, American Occupational Therapy Association (AOTA) staff, and a medical librarian. The review of the current available literature was then undertaken. 

 shows an example of the search strategy, including keywords used (all supplemental materials are available in a PDF at the end of the online article).

Inclusion criteria for studies were that the participants were adults (≥ 18 years) with MS; that the interventions addressed overall (general) ADL, other ADL (including falls and functional mobility, toileting hygiene/continence, and sexual activity), or sleep; and that the interventions were within the scope of OT practice (

). Articles had to have a quantitative methodology (as adapted by AOTA

1b: well-designed (low or moderate risk of bias), adequate sample size, individual randomized controlled trial (RCT)

2b: small sample, high risk of bias, or pilot study RCT; 2-group comparison, nonrandomized studies

3b: 1-group, noncontrolled, pretest-posttest studies.

Articles excluded were those published before 2011, systematic reviews, conference presentations, and those not published in English.

The methodologist at AOTA provided 602 articles for the first phase of the search (

). Seventy-five articles were screened by all authors to establish inter-rater reliability. After 2 rounds of review and discussion for article inclusion, there was perfect or near agreement (eg, 2 yes and 1 maybe) for 92% of the articles.

Of these 527 articles, each author took one-third for screening. Questions were discussed by the authors until they were resolved. For example, studies on functional mobility were excluded if they only used ambulation as an intervention, or if they only measured balance or gait outcomes, but were retained if they measured fall incidence or efficacy (Figure 1). No articles were added from hand searching. From the 602 articles, 26 were confirmed. During the updates, 974 articles were located by the university librarian. Each author screened one-third for inclusion. Another 13 articles were identified. In a final update by the third author (G.S.T.), 6 articles were added, making a total of 45 from January 2011 through July 2023.

Data were extracted from the full text of the 45 confirmed articles. The categories sleep (C-H.Y.), falls and functional mobility (S.F.), toileting hygiene/continence (G.S.T.), and sexual activity (G.S.T.) were apparent and predominated

Remaining studies measured participants’ overall ADL, and thus were categorized as 

 ADL (C-H.Y.). Information was entered into an evidence table (

). Each author reviewed the others’ table entries to strengthen format consistency. The early phase table was edited by AOTA methodologists for uniformity with concurrent reviews.

Assignment of level of evidence was made for all retained articles according to the hierarchy of the Oxford Centre for Evidence-Based Medicine,

Confirmed articles were assessed for risk of bias (low, moderate, or high) using methods specifically designed for nonrandomized and randomized trials (Levels 1b and 2b

), and for 1-group pre-post studies (Level 3b) using the National Heart, Lung, and Blood Institute

). Each of the authors reviewed one-third of the list, and consulted together to ensure uniform assessment. For example, “study participants were representative of real-world patients” was interpreted as participants were representative of the target population of adults with MS and were not drawn from a subpopulation (eg, ambulatory) of convenience. Also, “outcome measures were collected multiple times” was interpreted as outcome measures were collected at least at preintervention, postintervention, and 1 follow-up time.

During an early review of the articles, an additional inclusion criterion was selected. Only articles with clearly reported ADL or sleep outcomes were kept. Studies using only assessments of quality of life that contained just 1 or 2 items pertaining to ADL performance were excluded. Studies only evaluating the severity of fatigue were also excluded, as they did not directly measure ADL or sleep outcomes.

The principal approach was a descriptive synthesis. Articles from each category were divided into subcategories by type of intervention studied. Each subcategory was assigned a strength of evidence level (strong, moderate, or low) to indicate justifiable confidence in that finding.

 This appraisal was based on the number of articles, level of evidence, risk of bias, and statistical significance of the findings (Table S2).

This systematic review of interventions within the scope of OT practice for improving ADL performance and sleep in adults with MS found 45 relevant articles (see 

). The studies were categorized into 5 themes: sleep (11 studies), general ADL (7 studies), falls and functional mobility (13 studies), toileting hygiene/continence (4 studies), and sexual activity (10 studies). No studies examining the specific ADL outcomes of bathing/showering, eating/feeding, dressing, or grooming were found. Of the 45 studies, 19 were evidence Level 1b, 15 were Level 2b, and 11 were Level 3b. Most studies were conducted in outpatient or community settings, generally on individuals with less severe MS. Follow-up times ranged from none to 21 months (Table S5). See 

The total number of participants across the categories varied: sleep (N = 503), general ADL (N = 293), functional mobility and falls (N = 769), sexual activity (N = 674), and toileting hygiene/continence (N = 92). Risk of bias ranged from low (n = 15) to moderate (n = 29) to high (n = 1; see Tables S3 and S4). None of the studies reported adverse events.

Mindfulness-Based Cognitive Interventions

Due to differing conditions and results, there is moderate strength of evidence (1 Level 1b study,

 risk of bias moderate; 1 Level 2b study,

 risk of bias high; and 1 Level 3b study,

 risk of bias moderate) supporting the immediate effects of an 8-week mindfulness-based cognitive training in a home setting (for adults with relapsing-remitting or secondary progressive MS with severe fatigue) for the mitigation of sleep disturbance symptoms. Cavalera et al

 found that, compared with those who received psychoeducation, adults with MS who received mindfulness-based cognitive training demonstrated statistically significant improvement of sleep symptoms at posttest (Medical Outcome Study Sleep scale); however, no retention effects were found at 6 months. Lorenz et al

 reported that, after receiving an 8-week mindfulness-based stress reduction course combined with sleep hygiene education, adults with MS showed immediate reduction of nighttime awakening, but no significant improvement at 3-month follow-up. Hoogerwerf et al

 reported that, after receiving mindfulness-based cognitive therapy, no statistically significant improvement in sleep symptoms was found in adults with MS who experienced severe fatigue, (sleep subscale of Symptom Checklist-90), across pretest, posttest, and 3-month follow-up.

Cognitive Behavioral Therapy (CBT) Interventions

Despite inconsistent sample characteristics, there is strong strength of evidence (3 Level 1b studies,

 all with moderate risk of bias) supporting the use of CBT to improve sleep. In addition to the immediate effect,

 statistically significant therapeutic effects of CBT interventions (Pittsburgh Sleep Quality Index [PSQI]) were maintained at 4 weeks for women with MS

 and at 20 weeks for adults with MS with depressive symptoms.

 Although no statistical analysis was performed, Clancy et al

 reported a positive immediate effect of CBT on increased total sleep time in 73% of the sample (mean, +1.5 hours). Decreased daytime sleepiness was a statistically significant mediator in reducing fatigue for adults with MS who had severe fatigue after receiving a 16-week CBT intervention.

There is moderate strength of evidence supporting aerobic exercise for addressing sleep symptoms

 (2 Level 2b studies, risk of bias low). A 12-week moderate-intensity protocol brought statistically significant improvement in daytime sleepiness (Epworth Sleepiness Scale) and sleep quality (PSQI) for ambulatory adults with relapsing-remitting or secondary progressive MS.

 No statistical differences in outcome, however, were found between participants who received the aerobic exercise and those who did low-intensity walking and stretching. Al-Sharman et al

reported that, compared with those who received low-intensity nonaerobic exercise, participants (1 month relapse-free) receiving 6 weeks of moderate aerobic exercise showed statistically significant improvement in sleep quality (PSQI and Insomnia Severity Index) and sleep efficiency (ActiGraph device).

There is a moderate strength of evidence (1 Level 1b study, risk of bias low) that a web-based physical activity program did not improve sleep for persons with MS. Pilutti et al

 found no statistically significant difference in improvement in sleep quality (PSQI) after a 6-month web-based education program for ambulatory adults with MS, compared with the control group.

Low strength of evidence (1 Level 1b study, risk of bias low) supported a self-management OT intervention. Kos et al

 examined the effectiveness of a self-management OT intervention of 3 weekly 60- to 90-minute sessions based on energy conservation for ambulatory adults with MS who were highly affected by fatigue. Participants showed statistically significant improvement in ADL function after intervention as measured by the Canadian Occupational Performance Measure (COPM). However, Kos et al

 found no significant differences between those who received the OT intervention and those who received relaxation therapy.

Multidisciplinary/Interdisciplinary Rehabilitation

Moderate strength of evidence supported rehabilitation programs that were multidisciplinary/interdisciplinary (1 Level 1b study,

 found no statistically beneficial effects of a multidisciplinary outpatient rehabilitation program for ambulatory adults with MS who experienced fatigue in improving ADL function as measured by the Functional Independence Measure (FIM). Karhula et al,

 however, found that participants with either moderate or severe disability showed statistical improvement in performance and satisfaction on the COPM after receiving a 2-year outpatient multidisciplinary rehabilitation. In addition, Lexell et al

 reported that 42% and 56% of studied adults with MS showed clinically relevant changes in performance and satisfaction, respectively, on the COPM, after receiving an inpatient interdisciplinary rehabilitation program. No statistical analysis on the effectiveness of the program was reported.

There was low strength of evidence (1 Level 3b study, risk of bias moderate) supporting the effectiveness of a cognitive occupation-based program. Reilly and Hynes

 found statistically significant improvement in ADL function 1-week after a cognitive occupation-based program as measured by a Goal Attainment Scale for adults with MS who had mild cognitive difficulty and were clinically stable. They also reported clinically significant improvement in occupational competencies, measured by the Occupational Self-Assessment Daily Living Scale, at an 8-week follow-up.

There was moderate strength of evidence that a dexterity training program (1 Level 1b study, risk of bias low) improved self-perceived ADL function. Kamm et al

 compared the immediate effect of a 4-week home-based dexterity training program (5 days a week for 30 minutes) with a resistance training program for adults with relapsing-remitting, secondary progressive, or primary progressive MS who had dexterity problems. Participants in the intervention group showed statistically significant improvement in dexterity-related ADL, measured by a dexterity-related ADL questionnaire.

There was low strength of evidence (1 Level 3b, risk of bias low) supporting a 5-week aerobic exercise training program with statistically significant improvement in ADL function (via FIM).

 Effects were maintained at 4 to 6 months.

The category of functional mobility had 13 studies with fall incidence or efficacy as a direct outcome.

Strong strength of evidence supports exercise for balance and strength as an intervention to reduce falls in people with MS (13 studies: 4 Level 1b studies

 (3b, risk of bias moderate) found that an outpatient exercise program provided to frequent fallers with MS resulted in a decrease in self-reported falls. Coote et al

 (1b, risk of bias moderate) found a more than 50% reduction in falls in people who participated in a targeted 10-week outpatient group exercise program. A 5-week program of dynamic neuromuscular stabilization exercises was superior to core stability exercises in reducing fall incidence in adults with MS

 (1b, risk of bias low). In an exercise program using virtual reality (VR), participants with relapsing-remitting MS showed statistically significant improvement in fall efficacy (confidence in ADL performance) after 12 sessions

 (2b, risk of bias low). Significant gains in mobility confidence at 3-month follow-up came with a VR program

 (2b, risk of bias moderate). Additionally, a study of VR-based exercises in combination with calming sensory input (lavender oil) significantly reduced falls in ambulatory adults with MS

 (2b, risk of bias moderate). Cattaneo et al

 (1b, risk of bias low), however, found that compared with interventions aimed at activity and body function level, the effect of a 20-session balance training program to reduce fall frequency for ambulatory adults with MS was not statistically better than the standard physical therapy. Evidence from 5 studies

 moderately supports education combined with a targeted exercise program to reduce falls (1 Level 1b study

 study with low risk of bias; 3 Level 3b studies, with low

Four studies (3 Level 2b, 1 Level 3b) addressed toileting hygiene in terms of continence and incontinence.

Pelvic Floor Training With or Without Electronic Stimulation

Three studies examined the effect of pelvic floor muscle training (PFMT) on incontinence impact and quality of life in women with MS. With moderate strength of evidence, 2 Level 2b studies

 (risk of bias moderate) found that women with relapsing-remitting MS who received PFMT (two 30-minute sessions/week for 4 or 6 months) showed statistically significant improvement in continence.

 Also with moderate strength of evidence, 2 Level 2b studies

 (risk of bias moderate) found that electronic stimulation with PFMT (1 hour per week for 10 weeks or 6 months) improved continence statistically significantly more than PFMT alone.

There is low strength of evidence (1 Level 3b, risk of bias moderate) supporting the effect of a yoga program (including pelvic floor exercises) for 2 hours a day for 21 days improving incontinence.

The 10 studies related to sexual activity were conducted with female participants in outpatient or community settings.

Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) Model

Five studies (all Level 1b, risk of bias moderate) examined the effect of counseling using the PLISSIT model.

 There is strong strength of evidence that using PLISSIT produced a statistically significant increase in self-reported sexual function, either through 4 weekly 60- to 100-minute sessions,

 90- to 120-minute sessions, or once weekly 60- to 90-minute sessions,

 generally with gains retained after 2 to 3 months.

) used PFMT (with or without biofeedback, physical agent modalities, or mindfulness) to improve self-reported sexual function for women with clinically stable MS. There is moderate strength of evidence for its effectiveness.

 (risk of bias low) found that 12 weeks of 2 weekly sessions of PFMT, with or without neuromuscular electrical stimulation (NMES) and with or without transcutaneous tibial nerve stimulation (TTNS), yielded a statistically significant improvement in self-reported arousal, lubrication, and satisfaction in women with MS. In addition, participants receiving NMES had statistically significantly better pain relief than those receiving TTNS. Afshari et al

 (3b, risk of bias moderate) found that women with relapsing-remitting or secondary progressive MS (3 months relapse-free) who performed PFMT 3 times a day for 12 weeks (plus 10-20 contractions immediately after sexual intercourse or urination) reported statistically significant improvement on the Female Sexual Function Index (FSFI). There is a low strength of evidence

 (2b, risk of bias moderate) that mindfulness alone, or PFMT with mindfulness, compared with PFMT alone, improves self-reported sexual function.

There is moderate evidence (1 Level 1b, risk of bias moderate) that five 90-minute sessions of education, CBT, and mindfulness statistically improved scores on the FSFI total and 5 of its 6 domains in women with all MS subtypes claiming sexual dysfunction over the control group.

There is also moderate strength of evidence (1 Level 1b, risk of bias moderate) that 90-minute Good Enough Sex model sessions once a week for 3 weeks brought about immediate, significantly improved sexual satisfaction and sexual intimacy in married women with relapsing-remitting or primary or secondary progressive MS compared with the control group receiving routine neurologic MS care.

Among ADL and sleep-focused interventions, there was strong evidence in support of the PLISSIT model for addressing sexual dysfunction, CBT for improving sleep, and targeted exercise for reducing falls and improving functional mobility. Mindfulness training showed moderate strength of evidence for improving sleep. In addition, PFMT, with or without physical agent modality use, had a moderate strength of evidence for improving self-reported sexual function in women with MS. Mindfulness training with CBT and the Good Enough Sex model also produced a moderate strength of evidence for improving self-reported sexual function. Dexterity training showed a moderate strength of evidence for improving general ADL function. Evidence of effectiveness for other interventions, including aerobic exercise, yoga, web-based video coaching, and self-management OT intervention, was low.

Adults with MS and less than severe fatigue may benefit from online or in-person cognitive interventions to reduce sleep symptom severity. Ambulatory adults with MS may benefit from individual, home-based aerobic exercise to reduce daytime sleepiness. Interventions for the improvement of sleep problems should focus on CBT and may include appropriate aerobic exercise.

There is evidence suggesting that adults with MS may benefit from occupation-based interventions to improve general ADL function. Most interventions included were developed based on energy conservation,

 OT practitioners should aim for the occupational performance level when working with this population, eg, using functional tasks requiring dexterity to enhance ADL performance.

OT practitioners should consider interventions that reduce falls in people with MS by providing tailored education about fall causes, along with a targeted exercise program. Practitioners should emphasize fall prevention as a valuable OT intervention for functional improvement. Direct ADL measures should be utilized to evaluate client progress.

Women with relapsing-remitting or secondary progressive MS who experience incontinence may benefit from PFMT to improve self-reported life impact of incontinence. OT practitioners should consider interventions including PFMT, with or without physical agent modalities, for people with MS whose incontinence affects their ADL function.

Strong strength of evidence supports the use of outpatient or community-based counseling using the PLISSIT model for women with MS to increase self-reported sexual function. Moderate evidence exists for the use of PFMT, of mindfulness training plus CBT, and of the Good Enough Sex model to improve self-reported sexual function. Retention of therapeutic effects beyond 3 months has not been studied.

Additional research is needed to reveal the influence of cultural expectations on ADL performance. For example, evidence for the PLISSIT and Good Enough Sex programs for improving sexual dysfunction comes only from studies on married women with MS living in an Islamic society.

 Evidence for an inpatient integrated yoga program (2 hours a day for 21 consecutive days) improving incontinence for women with MS may be unique to the health system in Germany, which allows for a 3-week “Kur” (therapeutic spa visit). The extent to which these findings are generalizable to other countries and cultures is unknown. Researchers and practitioners should be aware of the uncertain generalizability of study findings to countries other than the ones where the reviewed studies were conducted, or to nonrepresented demographic and diagnostic categories of individuals.

Role of OT Within the Multidisciplinary Care Team

The complexity of the needs of individuals with MS requires holistic care. Individuals with MS can benefit from multidisciplinary care that comprehensively manages their diverse physical, cognitive, and emotional needs.

 Accordingly, health care professionals within the collaborative model may include physical therapy, OT, nutrition, nursing, speech therapy, neurology, and psychology.

 Our findings support the role of OT in the multidisciplinary care team in addressing goal setting and functional outcomes, specifically ADL and sleep. OT practitioners can work on reducing the risk of falls, improving functional mobility, toileting hygiene, and/or sleep severity, or refer to another health care professional for intensive care addressing sexuality using the PLISSIT model.

Comparison of Current Findings to Previous Review

 fewer studies in the current review examined the effects of rehabilitation in different settings. In the earlier review, there were 5 inpatient, 3 outpatient, 3 home-based, and 3 functional mobility programs where general ADL function was used to cover a broad range
of occupations.

The current review yielded more studies measuring specific aspects of ADL and sleep, including toileting hygiene/continence, sexual activity, functional mobility and falls, and sleep. These findings support expanding the involvement of occupational therapists in MS care when empirical evidence of the effectiveness of interventions within the scope of practice has been documented.

One important difference between the 2 reviews was that the current review excluded fatigue management programs that measured fatigue as their outcome because of their unknown connection to improving ADL function. Earlier articles on fatigue management had shown strong evidence for its effectiveness in reducing fatigue.

 The previous review contained telehealth and health promotion programs. These were not discovered in the current review, although 2 studies delivered web-based interventions.

 did not include articles describing interventions with outcomes pertaining to sleep, toileting hygiene/continence, or sexual activity. Nonetheless, the articles included in the present review were drawn only from the years 2011 to 2023. Therefore, pertinent earlier studies on these topics will not have been included either in Yu and Mathiowetz or in the current review.

This review was based on a search of studies published in English, indexed in 5 databases. Other relevant studies may exist. The average risk of bias for Level 1b and Level 2b was moderate due to omissions in study design and the use of self-reported outcome measures, thus affecting internal validity. The majority of included studies were conducted in countries other than the United States (36 vs 9). Thus, the perennial issue of the generalizability of published studies to local professional practice is particularly of note.

Greater uniformity in ADL outcome measures in published research on people with MS would be beneficial. Research conducted in 1 country needs to be replicated in countries with different cultures and health care systems. More studies could be conducted comparing outcomes among individuals with different subtypes or severity of MS. Longer follow-up intervals to determine the retention of effects are advised (40% of the currently reviewed studies had no follow-up). As the vast majority of the current 45 studies were conducted on individuals who were not experiencing a relapse (“clinically stable,” “relapse-free for 1 month”), there is an opportunity for future research to establish evidence for the effectiveness of interventions during exacerbation.

Five categories of ADL and sleep outcomes emerged from the 45 studies in this systematic review: general ADL, falls and functional mobility, toileting hygiene/continence, sexual activity, and sleep. Empirical evidence supports interventions using counseling, CBT, mindfulness, targeted exercise with education, and occupation-based activities to improve ADL and sleep function for certain individuals with MS. Occupational therapists may justifiably consider using these approaches in the selection of interventions for people with MS. Researchers, consumers, and practitioners should consider potential cultural, demographic, and diagnostic differences when applying findings.

Occupational therapists treating people with multiple sclerosis reporting sexual function challenges should consider a counseling intervention using the Permission, Limited Information, Specific Suggestions, and Intensive Therapy model or the Good Enough Sex model to improve self-reported sexual function.

Occupational Therapy Interventions Addressing Activities of Daily Living and Sleep for People With Multiple Sclerosis: A Systematic Review

Thousands of posters are presented at specialty meetings every year, and most are never published. In the second webinar of the International Journal of MS Care series on clinical publishing, Editor-in-Chief François Bethoux and Associate Editor Elizabeth Gromisch explain how to turn a poster into a journal article, and how to tell which posters should not become papers. Topics include the IMRAD structure, writing methods detailed enough for another team to replicate, reporting statistical and clinical significance with effect sizes and the minimal clinically important difference, defining your effect size descriptors, and writing a discussion that answers the reader’s “so what.” The webinar closes on authorship order, qualifying as an author, querying an editor before submission, disclosing the use of AI, and submitting within 90 days.

From Conference Poster to Published Paper: IJMSC Webinar 2

The annual meeting of the Consortium of Multiple Sclerosis Center alone generates about 150 posters each year, many of them from students and early-career researchers. They are seen by conference attendees during the poster session, but what about other clinicians? In our second webinar, 

 editor in chief François Bethoux, MD, and associate editor Elizabeth S. Gromisch, PhD, discuss what it takes to turn that poster into a paper ready for publication.

Not every poster should become a paper. Some are too specific to a single local unit; others rest on a small sample or a single detail of an analysis. Authors need to ask what the findings add to the field, and whether there is a unique angle, such as an assessment examined in a population where it has not been studied.

A poster tells its story through images and bullet points, but it contains the outline of a possible paper. The paper itself relies on text, with tables and figures that complement. It tells the full story of the research from idea to conclusions.

The Introduction contains the pared down specifics. Methods offer far more detail than a poster allows, including demographics, inclusion criteria, and the psychometrics of every measure used. Results should report statistical and clinical significance. Discussion and conclusions answer the question readers are really asking: So what?

Logistics are as much a part of the paper as the research, from authorship, defining each author’s role, the use of artificial intelligence, and how to stay on track to submission.

moving from the spark of an idea to a paper

. Webinar 3 covers the literature review that fills out your introduction and discussion, and webinar 4 closes the series with peer review.

IJMSC editors on converting a poster into a full manuscript: IMRAD structure, methods detail, clinical significance, authorship order, and AI disclosure.  

From Conference Poster to Manuscript: IJMSC Webinar 2

) in August 2026 spans the full arc of living with multiple sclerosis (MS), from how symptoms shape daily quality of life to how people approach decisions at the end of life. Two articles from the CMSC Aging and MS theme series tackle multidisciplinary care and disease-modifying therapy (DMT) decisions for older adults, while original research explores end-of-life perspectives in Saskatchewan, racial differences in symptom burden and health-related quality of life, and the cognitive and psychological contributors to standing balance.

Bringing Geriatric Care Into MS Care for Older Adults

Drawing on the 2024 CMSC Aging and MS Consensus Conference, 

 review what is known about multidisciplinary care and access barriers for older adults with MS. Because MS-specific evidence is sparse, the authors borrow from the broader geriatric literature, where comprehensive geriatric assessment has been linked to fewer hospitalizations, lower costs, and improved frailty outcomes. They map access barriers across availability, affordability, transportation, and equity, noting that nearly 20% of Medicare beneficiaries with MS travel 50 miles or more each way for neurologic care. Recommendations include building geriatric assessment into MS clinics, expanding telehealth and home-based care, and recognizing ageism and ableism as barriers to quality care.

End-of-Life Perspectives When Medical Assistance in Dying Is an Option

In what the authors believe is the first qualitative study of its kind, 

 interviewed 22 people with MS and 5 key informants in Saskatchewan, a province with one of the world's highest MS prevalence rates, about end of life where medical assistance in dying (MAID) is legal. Three themes emerged: retaining self-agency, combating stigma, and leaning into hope and positivity. Participants valued decision-making autonomy but recognized that cognitive change could complicate it, so they relied on family and clinicians for cues about their cognition. The authors call for open, nonjudgmental conversations among people with MS, families, and care teams throughout the disease course.

Weighing DMT Continuation, Discontinuation, and De-Escalation After 55

Although 46% of US adults with MS are 55 or older, most pivotal DMT trials excluded this group, leaving clinicians with little direct evidence, according to a second theme series review by 

. The authors synthesize observational data and the DISCOMS and DOT-MS discontinuation trials, which show that recurrence risk is concentrated in younger patients with recent disease activity. For clinically stable people older than 60, stopping DMT mainly carried an added risk of 1 to 2 new MRI lesions of unclear long-term significance, while risks such as infection, malignancy, and vascular effects may rise with age. Continuing, discontinuing, or de-escalating can each be reasonable, the authors conclude, as long as clinical and MRI monitoring continues.

Which Symptoms Drive Quality of Life in Black and White People With MS

 surveyed 136 Black and 273 White adults with MS on walking impairment, fatigue, depression, anxiety, and health-related quality of life (HRQOL). In both groups, walking impairment and fatigue were the strongest correlates of physical HRQOL after adjusting for age and household income. For mental HRQOL, the picture diverged: anxiety and depression were both significant among White participants, whereas anxiety alone remained significant among Black participants. Contrary to the authors' hypothesis, Black participants reported less fatigue and depression and better mental HRQOL, which they suggest may reflect resilience and social support.

Cognition, Fear of Falling, and Standing Balance

 measured sway with inertial sensors as 54 ambulatory people with MS stood under 4 progressively harder conditions, varying eyes open or closed and feet apart or together. Processing speed (Symbol Digit Modalities Test) was tied to sway in the easiest condition, while attention (Trail Making Test part A) and concern about falling took over as predictors once vision was removed. Concern about falling was the strongest independent predictor in the hardest condition, even after adjusting for age, sex, and disability. The authors suggest brief cognitive screens and the Falls Efficacy Scale-International may add useful context to fall-risk assessments.

Taken together, August's research makes a case for looking past the neurological exam alone. Whether the question is how to care for an aging population, which symptoms to target first, what predicts a fall, or how people want to approach the end of life, these studies point toward care that accounts for age, cognition, emotional health, and personal values. 

128 accepted abstracts from the 2026 Rehabilitation in Multiple Sclerosis (RiMS) Conference

 in August, offering an early look at emerging MS rehabilitation research. 

The full arc of living with multiple sclerosis, from how symptoms shape daily quality of life to how people approach decisions at the end of life.

IJMSC August 2026 Research Roundup

Tumefactive demyelination (TD) is often misdiagnosed as central nervous system malignancy. We report on 4 patients 65 years or older with TD whose initial misdiagnosis led to biopsy or resection. This series draws attention to TD as an uncommon cause of cerebral lesions in older patients. We highlight the importance of MRI and ancillary tests to diagnose TD and avoid invasive investigations.

 The authors received no financial support for this article.

Carla De Pasquale, MD, has no disclosures. Michael H. Barnett, PhD, has received speaker honoraria and scientific advisory board fees from Alexion, Clene Nanomedicine, Merck, Novartis, Roche, and UCB; is a cofounder of RxPx; and is research director for the Sydney Neuroimaging Analysis Centre. Todd A. Hardy, PhD, has received speaker honoraria, conference support, and scientific advisory board fees from Alexion, Bayer Schering, Biogen Idec, Bristol Myers Squibb, Merck, Novartis, Roche, Sanofi-Genzyme, and Teva.

Tumefactive demyelination (TD) refers to a demyelinating brain lesion that mimics a central nervous system (CNS) tumor on neuroimaging.

 TD occurs in up to 8.2% of cases of multiple sclerosis (MS).

TD can present in patients with or without known MS.

 Symptoms vary depending on lesion location and associated edema or mass effect.

 MRI is useful for making the diagnosis and excluding common alternative diagnoses such as CNS malignancy, metastasis, or lymphoma, although misdiagnosis can occur.

Brain biopsy should be considered for patients with imaging atypical for TD or when there is a high suspicion of CNS neoplasm.

 Intravenous corticosteroids are commonly used to treat acute attacks,

Although more common in younger patients, tumefactive demyelination can occur in adults 65 years and older. It should be considered as a differential diagnosis in patients of this age presenting with a central nervous system lesion.

Erin Lampron, DPT, PT

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