449

Efficacy of an Energy Conservation Course for Persons With

Multiple Sclerosis
Virgil Mathiowetz, PhD, OTR, Kathleen M. Matuska, MPH, Megan E. Murphy, MA
ABSTRACT. Mathiowetz V, Matuska KM, Murphy ME. (QOL). 2 Education regarding energy conservation principles,
Efficacy of an energy conservation course for persons with including work simplification and time management, is a tra-
multiple sclerosis. Arch Phys Med Rehabil 2001;82:449-56. ditional occupational therapy (OT) intervention for managing
fatigue. 3 Research regarding its efficacy, however, is limited.
Objective: To evaluate the efficacy of an energy conserva- This study evaluated the efficacy of an energy conservation
tion course on fatigue impact, self-efficacy, and quality of life course developed by Packer et al4 for persons with MS.
(QOL) for persons with multiple sclerosis (MS).
Design: Repeated measures with control and experimental R E V I E W OF T H E L I T E R A T U R E
interventions conducted during a 19-week study.
Setting: Community-based treatment center. Multiple Sclerosis
Participants: A convenience sample of 54 individuals from
79 community-dwelling volunteers with fatigue secondary to MS is an inflammatory, demyelinating disease of the central
MS. nervous system. In the United States, it is the most common
Intervention: A 6-session, 2-hr/wk energy conservation chronic and disabling neurologic disease. Approximately
course taught by occupational therapists for groups of 8 to 10 500,000 cases have been diagnosed, and it is estimated that as
participants. many as 8000 new cases are diagnosed each year. 5 Although
Main Outcome Measures: Fatigue Impact Scale (self-re- some medications enable true disease management, the pri-
port measure of fatigue impact on cognitive, physical, social mary focus of treatment remains symptom management. 6
functions), Self-Efficacy Gauge (self-report measure of confi-
MS Fatigue
dence in ability to perform specific behaviors), and Medical
Outcomes Study Short-Form Health Survey (QOL measure). Persons with MS describe fatigue as a frustrating and over-
Results: Participants reported, as predicted, significantly whelming symptom that can be disabling. 7 Packer et al8 de-
less fatigue impact, increased self-efficacy, and improved QOL scribed fatigue as a state characterized by extreme tiredness, an
(ie, 3 of 4 subscales expected to improve). There were no overwhelming need to rest, a complete lack of energy, and a
significant differences, as predicted, in any of the dependent decreased capacity for physical or mental work. Krupp I pro-
variables after the control (ie, support group) and no interven- vided evidence that MS fatigue has the following unique char-
tion periods. acteristics: (1) it occurs more frequently and is more severe
Conclusion: Results provide strong evidence for the efficacy than normal fatigue, (2) it prevents sustained physical func-
of this energy conservation course for persons with MS. tioning, (3) it comes on quickly and recovery from it takes
Key Words: Conservation of energy resources; Fatigue; much longer than normal fatigue, (4) it exacerbates other MS
Multiple sclerosis; Rehabilitation. symptoms, (5) it is worsened by heat, (6) it is chronic, and (7)
© 2001 by the American Congress of Rehabilitation Medi- its severity it not always related to neurologic status or other
cine and the American Academy of Physical Medicine and MS symptoms.
Rehabilitation Schapiro 9 described 4 types of fatigue that may be experi-
enced by MS patients. Normal fatigue occurs as a result of
overworking during typical daily activities. A worn-out feeling,
F ATIGUE IS A COMMON and disabling symptom for
individuals with multiple sclerosis (MS), Krupp et all poor appetite, sleep disturbances, and feelings of poor self-
worth characterize fatigue associated with depression. Neuro-
reported that 87% of individuals with MS reported problems
with fatigue, with 28% describing it as their most troubling muscular fatigue is caused by inefficient nerve conduction.
Lassitude or MS fatigue, the most extreme type of fatigue, is
symptom. Fatigue can have a devastating effect on occupa-
characterized by feelings of overwhelming fatigue and sleepi-
tional and role performance as well as on overall quality of life
ness, which occur without warning at any time of day. Indi-
viduals with MS may experience any or all of these types of
fatigue. Across time, different types of fatigue may play a
From the Department of Physical Medicine & Rehabilitation, University of Min-
dominant role in the life of a person with MS. We speculate
nesota, Minneapolis (Mathiowetz); Department of Occupational Therapy, College of that the use of energy conservation principles would benefit all
St. Catherine, St. Paul (Matuska); and Services to Persons with Mobility Impairment, 4 types of fatigue.
Accessible Spaces, St. Paul (Murphy), MN.
Accepted in revised form February 16, 2000. Energy Conservation Strategies to Manage MS Fatigue
Supported by grants from the Minnesota Medical Foundation and the American
Occupational Therapy Foundation. Several studies have explored the strategies used by patients
Presented in part at the Minnesota Occupational Therapy Association State Con- with MS to decrease feelings of fatigue. McLaughlin and
ference, October 29, 1999, Minneapolis, MN.
No commercial party having a direct or indirect interest in the subject matter of this
Zeeberg 7 reported that as many as 91% of subjects with MS
article has or will confer a benefit upon the anthor(s) or upon any organization with used a range of self-care behaviors to manage their fatigue.
which the author(s) is/are associated. These behaviors included the following: learning to recognize
Reprint requests to Virgil Mathiowetz, PhD, OTR, Program in Occupational personal limits, scheduling activities when they had the most
Therapy, University of Minnesota, Mayo Mail Code 388, Minneapolis, MN 55455,
e-mail: [email protected]. energy, organizing their homes, resting during the day, sleep-
0003-9993/01/8204-5890535.00/0 ing regular hours, undertaking prolonged tasks in steps, using
doi: 10.1053/apmr.2001.22192 a cane or wheelchair to conserve energy, and avoiding exhaus-

Arch Phys Med Rehabil Vol 82, April 2001

450 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz

tion. It was not clear whether these behaviors were taught by a energy conservation course improves self-efficacy, it may be
health care professional or learned through trial and error. an explanatory factor for any changes in the number and
Sears and Hubsky ~o reported that patients ranked delegating frequency of energy conservation behaviors.
tasks, naps, rest, and avoiding stress as the most effective The energy conservation course was evaluated in a pilot
strategies for managing fatigue. They also noted that newly study (n = 16) that found that 80% of the participants had
diagnosed individuals might not have learned these strategies. implemented at least 6 energy conservation principles in their
Schapiro 1~ described occupational therapists as "efficiency daily lives by the end of the course. 4 In addition, there were
experts" who are uniquely qualified to instruct patients in the positive trends for all measures of fatigue and a significant
areas of energy conservation, time management, and efficient reduction (p < .05) in the physical domain of the Fatigue
body mechanics and task performance. Schapiro 9 also stressed Impact Scale (FIS). 19 This assessment was sensitive enough to
that therapists should teach patients to spend time engaging in detect differences in fatigue on 1 of its 3 domains using a small
activities that are most important to them. In addition, energy sample and was more sensitive to change than the Fatigue
conservation also includes work simplification principles such Severity Scale (FSS)? ° Packer et al4 suggested that, with a
as limiting the amount of work, planning ahead, using correct larger sample size and increased statistical power, significance
body mechanics, using efficient methods, using correct equip- would be expected on the other domains of the FIS. They
ment, and rest. ~2-13 recommended that future studies include larger samples and a
long-term follow-up.
OT and Energy Conservation Education Programs
The primary purpose of OT is to enable individuals to Purpose
participate in self-care, work, and leisure activities that they
This study replicated and advanced the Packer 4 study by
want or need to perform. Fatigue impairs the performance
using a larger sample, by using only adults with MS, by adding
component, endurance. When fatigue interferes with occupa-
a control intervention, by adding assessments of self-efficacy
tional and/or role performance, instruction in energy conserva-
and QOL, and by adding assessments 6 weeks after the course
tion strategies is indicated. Feinberg and Trombly 14 defined
to determine whether the course benefits were maintained over
energy conservation principles as "guidelines for performing
time. Our specific aims were to determine the efficacy of the
important occupational performance tasks in such a way as to
6-week energy conservation course 4 on fatigue impact, self-
conserve personal energy." Several occupational therapists
efficacy, QOL, and energy conservation behavioral change in
have developed energy conservation education programs for
persons with MS.
individuals with various chronic illnesses and have conducted
Three hypotheses were proposed: (1) individuals with MS
pilot studies on their effectiveness.
will report significantly less fatigue impact, increased self-
Furst et a115 developed a workbook to teach energy conser-
efficacy, and improved QOL after the energy conservation
vation and joint protection to persons with rheumatoid arthritis.
course than before it; (2) individuals with MS will maintain any
The energy conservation program consisted of 6 weekly, 1.5-
improvements in these variables in the 6 weeks after the
hour sessions with 2 to 4 participants per group (experimental
course; and (3) there will be no significant differences in these
group, n = 16). Results indicated a trend of increased energy
variables before and after a control intervention. In addition,
conservation behaviors and an overall increase in activity, but
we expected 80% of the participants to implement at least 6
these changes were not statistically significant. It was recom-
energy conservation behaviors by the end of the course?
mended that future studies use larger sample sizes, more sen-
Occupational therapists routinely teach energy conservation
sitive measures of change, and a longer follow-up period/6
strategies to individuals with fatigue problems that interfere
Young 17 developed an OT education program for individuals
with occupational or role performance. 21 Only a few studies
experiencing postpoliomyelitis sequelae (n = 35). The pro-
have attempted to evaluate the outcomes of energy conserva-
gram consisted of 3 weekly, 2-hour classes, which included
tion education. None have addressed this issue with MS clients
information on the condition and on energy conservation strat-
alone, with a large sample, or with a 6-week follow-up. In
egies. The energy conservation portion of the program was
1998, the Multiple Sclerosis Council for Clinical Practice
based on the energy conservation workbook for individuals
Guidelines 22 (MS Council) recommended that determining the
with rheumatoid arthritis. 1-~ The most frequently reported
effectiveness of energy conservation strategies in reducing the
changes 3 weeks after the program included "identifying and
severity of fatigue in individuals with MS was an important
changing incorrect work heights, changing location of equip-
direction of future research.
ment and supplies, changes in body and joint positioning,
increasing the amount of rest, and elimination or delegating
portions of activities.''17 METHODS
Packer et al4 developed a 6-week, community-based energy
conservation course for adults experiencing fatigue secondary Participants
to several chronic illnesses (eg, MS, postpolio syndrome, Volunteers were recruited through mailings from the Min-
chronic fatigue syndrome, fibromyalgia). The course "does not nesota chapter of the National Multiple Sclerosis Society. Sev-
aim to correct the underlying mechanisms that cause fatigue, enty-nine volunteers who met the inclusion criteria at screening
nor does it accept that the solution is to decrease activity levels were enrolled in the study. To be included, participants had to
or reduce the breadth and extent of activities. Rather it pro- have a diagnosis of MS; be 18 years of age or older; be
motes a positive attitude aimed at active decision-making and functionally literate (ie, able to read course materials); have a
optimum use of available energy to fit the unique needs of each FSS 2° score of 4 or higher (ie, moderate-to-high fatigue im-
individual. TM The active learning activities used in the energy pact); live in the community; and be independent in most
conservation course were expected to improve the participants' self-care and daily activities (ie, not receiving personal care or
self-efficacy for managing their fatigue. Self-efficacy is confi- homemaker services > 10hr/wk).
dence in one's ability to perform a specific behavior. Improve- Participants were excluded if they did not attend at least 5 of
ments in self-efficacy have been shown to play a central role in 6 support group and energy conservation sessions; experienced
the performance of various health behaviors? 8 Thus, if the an exacerbation of MS symptoms; had fatigue medication

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 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz 451

changes; or had other major illnesses, hospitalizations, or re- dependent variables, fatigue impact, self-efficacy, and QOL,
habilitation during the 19-week course. Twenty-five volunteers were assessed 4 times during weeks 1, 7, 13, and 19.
were e x c l u d e d - - 8 because they did not attend any sessions
after enrolling; 9 because they attended fewer than 5 sessions Independent Variables
of each intervention (unexpected schedule conflicts, n = 5; Control intervention. This intervention consisted of 6
vacations, n = 2; poor fit, n -- 1; transportation, n = 1); 4 weekly 2-hour support group sessions involving education on
experienced exacerbation of MS symptoms during the study; 3 and discussion of topics commonly addressed in support
had health problems unrelated to MS; and 1 had cognitive groups for individuals with MS and other chronic diseases. The
problems that prevented learning and practicing energy con- group generated a list of prioritized topics of interest, and the
servation principles. None of the participants were involved in occupational therapist gathered educational materials, video-
a rehabilitation program or had fatigue medication changes tapes, and other resources as a basis for discussions. Topics
during the study. included basic information on MS, medications, financial is-
Fifty-four subjects completed the 19-week study. Demo- sues, estate planning, the Americans with Disabilities Act,
graphic and MS-related information on the 54 participants reasonable accommodation, dealing with others expectations,
appear in table 1. Eighty-three percent of them reported fatigue nutrition, exercise, memory problems, hiring an aide, and com-
as a primary symptom, and 11% reported taking only medica- munity resources. When fatigue management issues were
tion for symptoms of fatigue. Twenty percent had a secondary raised, participants were told that these issues would be dis-
diagnosis (eg, depression) that could contribute to fatigue, and cussed during the second 6 weeks. The same occupational
18% reported taking medication only for symptoms of depres- therapist led the support group and the energy conservation
sion. Twenty-three percent reported taking medication for both
course for each group.
fatigue and depression. Twenty-seven percent admitted having Experimental intervention. Four occupational therapists
some difficulty with memory but reported using compensatory with energy conservation education taught the courses. How-
strategies successfully (eg, writing things down). ever, none had used the energy conservation course by Packer
et ala before this study. The course protocol was easily repli-
Design
cated because of the step-by-step procedures outlined in the
A repeated-measures study design was chosen to help con- manual. 4 Each therapist was instructed to follow the protocol in
trol for the differences between the participants with MS. In the manual. Each therapist observed at least 1 class before
addition, given the same number of participants, statistical teaching a course. A project director observed classes occa-
power increases by using a repeated-measures design. 23 A sionally to enhance treatment fidelity. Each group consisted of
6-week control intervention (support group) was included be- 8 to 10 participants. The 6 weekly 2-hour sessions addressed
fore the 6-week experimental intervention (energy conservation the importance of rest throughout the day, positive and effec-
course) to control for possible fluctuations in MS symptoms tive communication, proper body mechanics, ergonomic prin-
and for the Hawthorne effect. The experimental intervention ciples, modification of the environment, priority setting, activ-
was scheduled after the control intervention for all groups ity analysis and modification, and living a balanced lifestyle.
(rather than a crossover design) because the experimental in- The course used lectures, discussions, long- and short-term
tervention was expected to have carry-over effects. A 6-week, goal setting, activity stations, and homework activities to teach
no-intervention period followed the experimental intervention participants to integrate the energy conservation principles into
to determine whether changes were maintained over time. The their performance of everyday tasks.
No intervention. There was no intervention in the 6 weeks
after the course to determine if its benefits were maintained
over that time period.
Table 1: Participants' Characteristics (n = 54)

n % Dependent Variables
Gender
Fatigue. The FIS 19 was used to measure the impact of
Men 18 33
fatigue on participants' lives. The FIS was developed "to
Women 36 67
evaluate the perceived impact of fatigue on the lives of MS
Type of MS
patients, the factors that affect patients' perceptions of fatigue
Chronic progressive 12 22
impact, and how fatigue may affect the mental health and
Relapsing/remitting 20 36
general health status of MS patients. ''~9 The FIS consists of 40
Exacerbating/remitting 7 13
statements that measure fatigue in 3 areas: physical, cognitive,
Benign 4 7
and psychosocial. Respondents rate the statements on a Likert
Unknown 12 22
scale ranging from 0 (no problem) to 4 (extreme problem). The
Employment Status
FIS did discriminate between MS patients and hypertensive
Full-time outside home 22 41
patients, whose primary complaint was not fatigue. In addition,
Part-time outside home 16 30
patients with chronic fatigue syndrome had significantly higher
Disability status 6 11
FIS scores than MS patients, as predicted. Internal consistency
Full-time homemakers 4 7
of the FIS and subscales was very high (ie, Cronbach's a > .93
Retired 3 5.5
for all analyses). No evidence of test-retest reliability was
Unemployed 3
reported. All available fatigue assessment scales 19-2°.24,25 have
5.5
Other Variables*
some limitations. After evaluating them, the MS Council se-
Age (yr) 50 (31-74)
lected the FIS "as most appropriate for assessing the impact of
Years diagnosed 9.5 {1-34)
MS-related fatigue on quality of life. ''22 Other reasons for
FSS score 5,55 (4.0-7.0)
selecting the F1S for this study were that the items it includes
relate more to the behavioral changes expected in this study
* Data presented as mean (range). and that the FIS was used in the pilot study by Packer. 4

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452 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz

Self-efficacy, The Self-Efficacy Gauge (SEG) 26 was used once at the end of the course overestimated the course's im-
to measure participants' perceived self-efficacy for various pact. For the remaining 34 participants, the energy conserva-
functional tasks. The SEG was developed as an OT assessment tion usage survey was administered before and after the course
tool for clients experiencing occupational performance deficits. to determine more accurately behavior changes caused by the
Participants used a 10-point Likert scale to rate their confidence course itself. All participants were given a list of the 14 most
that they could perform 27 everyday tasks. Reliability and important energy conservation principles taught. They checked
validity data were collected on a sample (n = 102) of clients the principles that they were using in their daily lives and the
with chronic health problems. Test-retest reliability was very number of changes made. They were also asked to indicate
high (intraclass correlation coefficient [ICC] = .90). However, which principles were most and least helpful.
it was speculated that stressful life events might affect the
instrument's stability. To examine this possibility, the ICC Procedures
among those who experienced no stressful events (n = 48, Participants were recruited through a mailing by the Minne-
ICC = .95) was compared with that among those who expe- sota chapter of the National Multiple Sclerosis Society to its
rienced at least 1 event (n = 54, ICC = .86). This difference members in a large metropolitan area. We modified the recruit-
in correlations, although relatively small, provides some evi- ment flyer in Packer et al's 4 manual. Our flyer targeted indi-
dence of the sensitivity of the SEG. Internal consistency was viduals with MS who had fatigue severe enough to have a
also very high (Cronbach's o~ = .94), which supports the use of negative impact on their daily life and function. The flyer
the 27 items as 1 scale. Alternative forms reliability was also explained that our purpose was to determine the efficacy of a
supported with a high correlation (r = .72) between the SEG support group and an energy conservation course for adults
and perceived ability. The SEG correlated moderately (r = with fatigue secondary to MS. Interested candidates contacted
.44) with total performance checklist, a measure of occupa- the project director, who did an informal screening on the
tional performance. When only the 11 items that were identical
telephone. Potential participants who appeared to meet the
in the 2 instruments were analyzed, the correlation increased as screening criteria were invited to a pregroup session where they
predicted to r = .76. The SEG also correlated moderately were screened formally. Eligible candidates signed a consent
(r = - .47) with the Beck's Hopelessness Scale. 27 A negative form and a participatory contracP indicating their commitment.
correlation between self-efficacy and hopelessness was pre-
Then, each participant was given the following baseline assess-
dicted. The SEG has very strong reliability and some evidence ments: FIS, SEG, and SF-36. Finally, all eligible participants
of validity. In addition, it is the most appropriate measure of
were assigned to a group of 8 to 10.
self-efficacy for this study because participants with MS have One week after the pregroup session, each group began their
a chronic disease and have occupational performance deficits. control intervention of 6 weekly support group sessions. At the
A measure of self-efficacy was included in this study because
end of the last session, participants completed a second FIS,
Belza 28 suggested that enhanced self-efficacy might decrease SEG, and SF-36. One week later, each group began the exper-
fatigue. Thus, we included a self-efficacy measure to help imental intervention, the 6-week energy conservation course.
interpret the study results. At the end of the last session, participants completed the 3
Quality of life. The Medical Outcomes Study Short-Form assessments for the third time. All participants also completed
Health Survey (SF-36) 29 was used to assess participants' per-
the energy conservation usage survey. No further contact was
ceived QOL. The SF-36 is considered a generic measure of made with participants for the next 6 weeks (no intervention).
health-related QOL because it represents values that are rele- At the end of the sixth week, most participants returned to
vant to general functional status and well-being. It consists of complete a fourth and final FIS, SEG, and SF-36. Those
8 subscales: physical functioning, role-physical, bodily pain, participants unable to attend this session completed their final
general health, vitality, social functioning, role-emotional, and assessments at home and returned them through the mail. The
mental health. Based on the characteristics of the energy con- university's institutional review board approved the study for
servation course, a related self-management study by Mease et
human subjects.
al, 3° and the description of the subscales, 29 the energy conser-
vation course was expected to affect the vitality (ie, feels tired
and worn out all of the time), social functioning (ie, frequent Data Analysis
interference with normal social activities), mental health (ie, Because the FIS (total score) and SEG data met the assump-
feelings of nervousness and depression), and role-physical (ie, tions of parametric statistics, the data were analyzed using a
problems with work or other physical activities) subscales. The 1-way analysis of variance (ANOVA) of repeated measures.
energy conservation course was not expected to affect the other When the overall A N O V A was significant, paired t tests were
4 subscales. The internal consistency of the scales ranged from used to determine whether there were significant differences
.80 to .92 for patients with chronic conditions. Test-retest between the following planned comparisons: week 1 and week
reliability of the scales over a 2-week interval ranged from .60 7, to determine if there were changes because of the control
to .81 for general practice patients. This level of reliability is intervention; week 7 and week 13, to determine if there were
not considered acceptable for comparisons of individual pa- immediate changes because of the experimental intervention;
tients but is considered acceptable for group-level analyses. 29 and week 13 and week 19, to determine if changes were
Numerous studies support the validity of the SF-36. For exam- maintained after the experimental intervention.
ple, the vitality subscale correlates highly (r --- - . 6 8 ) with the Because the SF-36 and the FIS have multiple subscales, a
energy scale of the Nottingham Health Profile. 29 The SF-36 is multivariate analysis of variance (MANOVA) was run to con-
used widely in clinical outcome studies. trol for experiment-wise error. When the overall M A N O V A
Energy conservation behavioral change. The energy con- was significant, the subscales were analyzed individually using
servation usage survey 4 was administered at the end of the last 1-way ANOVAs of repeated measures. All multivariate and
class to the first 20 participants to determine how many energy univariate tests were performed using a significance level of
conservation behaviors were implemented. It became clear that p < .05. The follow-up paired t tests were performed using the
participants were using some of the behaviors before the more conservative p < .01 level of significance. Effect sizes
course. Thus, measuring the energy conservation behaviors were calculated for each variable for week 7 to week 13 using

Arch Phys Med Rehabil Vol 82, April 2001

 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz 453

Table 2: Descriptive Data, Results of 1-Way ANOVAs of Repeated Measures Across Time, and Effect Sizes
for the 3 FIS Subscales and Total Score (n = 54)

Week 1 Week 7 Week 13 Week 19

FIS Scales Mean SD Mean SD Mean SD Mean SD F3,159 d

Cognitive 14.7 a 9.3 14.0~ 8.6 12.0 b 9.1 11.9b 8.8 5.59* .53
Physical 22.0a 7.7 20.7 a 7.3 17.8 b 8.8 17.3b 8.2 11.86* .57
Social 32.2. 14.0 31.8a 14.5 26.1 b 15.5 25.2b 14.0 12.58" .66
Total 68.9 a 26.2 66.4~ 26.5 55.8 b 29.7 54.5b 27.3 13.86" .69

NOTE. L o w e r scores reflect decreased impact o f fatigue. Means in the same r o w that do not share the same subscripts are significantly
different ( p < .01) using paired t tests. The energy conservation course was taught between weeks 7 and 13, Effect size (Cohen's d) f o r
repeated-measures data 23 = mean of w e e k 7 - mean o f w e e k 13 ÷ the standard deviation × ~,/2.
* p < .001

Cohen's d for repeated-measures data 23 (ie, mean of week 7 - Self-Efficacy

mean of week 13 + the standard deviation of the difference Descriptive data on the SEG are reported in table 3. There
score X X/2). was a significant effect of time using a 1-way A N O V A of
Descriptive statistics were used to analyze the energy con- repeated measures. Follow-up planned comparisons (ie, paired
servation usage survey data and to provide information regard- t test) showed that there was a significant increase between
ing the implementation and practice of the principles taught in weeks 7 and 13 (ie, before and after the course) on the SEG
the energy conservation course. (table 3). These results support hypothesis 1, which predicted
significantly improved self-efficacy after the energy conserva-
RESULTS tion course. Effect size was medium? 3 There were no signifi-
cant differences in scores between weeks 1 and 7 (ie, before
Fatigue Impact and after the support group sessions) or between weeks 13 and
19 (ie, no treatment period). These results support hypothesis 3,
Descriptive data on the 3 subscales of the FIS and the FIS
which predicted no change in fatigue because of the support
total are reported in table 2. The general pattern of change
group sessions, and support hypothesis 2, which predicted that
across time was a larger decrease in FIS scores between weeks
the effects of the course would be maintained in the 6 weeks
7 and 13 and smaller decreases in FIS scores between weeks 1
and 7 and weeks 13 and 19. First, a 1-way ANOVA of repeated after the course.
measures determined that there was a significant effect of time
for the FIS total scores (table 2). Second, a M A N O V A was run Quality of Life
to determine the effects of time on the 3 FIS subtests. The Descriptive data on the 8 subscales of the SF-36 are reported
M A N O V A indicated a significant effect of time for the FIS in table 4. Because there are multiple subscales of the depen-
subscale scores (Wilks' A = .546, F9.45 = 4.16, p < .001). dent variable, a M A N O V A was run first. It indicated a signif-
Thus, use of 1-way ANOVAs of repeated measures for each icant effect of time for the SF-36 subscale scores (Wilks' A =
subscale was justified. The univariate tests indicated a signif- .338, F4.28 = 2.28, p < .05). Thus, use of 1-way ANOVAs of
icant effect of time for FIS cognitive, FIS physical, and FIS repeated measures for each subscale was justified (table 4).
social subscales (table 2). Third, follow-up planned compari- There was a significant effect of time for 3 SF-36 subscales:
sons (ie, paired t test) showed that there were significant vitality, social functioning, and mental health. For these sub-
decreases in scores between weeks 7 and 13 (ie, before and scales, follow-up planned comparisons (ie, paired t test)
after the course) for all 3 FIS subscales and total score (table 2). showed that there were significant increases in scores between
These results support hypothesis 1, which predicted signifi- weeks 7 and 13 (ie, before and after the course) (table 4). These
cantly less fatigue impact after the energy conservation course. results support hypothesis l, which predicted significantly im-
Effect sizes were medium to largeY There were no significant proved QOL for these subscales after the course. Effect sizes
differences in scores between weeks 1 and 7 (ie, before and were medium to large 23 for these subscales. There were no
after the support group sessions) or between weeks 13 and 19 significant differences in scores between weeks 1 and 7 (ie,
(ie, no treatment period). These results support hypothesis 3, before and after the support group sessions) and between weeks
which predicted no change in fatigue due to the support group 13 and 19 (ie, no-treatment period). These results support
sessions, and support hypothesis 2, which predicted that the hypothesis 3, which predicted no change in QOL because of
effects of the energy conservation course would be maintained the support group sessions, and support hypothesis 2, which
in the 6 weeks after the course. predicted that the effects of the course would be maintained in

Table 3: Descriptive Data*: Results of 1-Way ANOVA of Repeated Measures Across Time and Effect Size for the SEG (n = 53)

Week 1 Week 7 Week 13 Week 19

Mean SD Mean SD Mean SD Mean SD F3,166 d

SEG 201.5 a 36.3 206.1~ 40.4 214.0 b 35.8 214.5 b 35.8 8.18 t .52

NOTE. Higher scores reflect increased self-efficacy. Means in the same r o w that do not share the same subscripts are significantly different
( p < .01) using paired t tests. The e n e r g y conservation course was t a u g h t between weeks 7 and 13. Effect size (Cohen's d) for repeated-
measures data 23 = mean of w e e k 7 - mean of w e e k 13 ÷ the standard deviation x ~/2.
* One participant had incomplete data.
t p < .001.

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454 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz

Table 4: Descriptive Data*: Results of 1-Way ANOVAs of Repeated Measures Across Time and Effect Sizes
for the 8 SF-36 Subscales (n = 52)
Week 1 Week 7 Week 13 Week 19
SF-36 Subscales Mean SD Mean SD Mean SD Mean SD F3,153 d
Physical functioning 45.7 24 48.9 24 50.4 24 48.8 26 1.86 ,17
Role-physical* 26.9 29 29.8 38 37.5 36 26.9 34 2.25 .31
Bodily pain 67.2 26 71.8 24 71.4 24 70.8 23 1.44 ,03
General health 51.7 23 52.2 22 55.1 24 54.3 23 1.82 .34
Vitality* 34.1a 18 35.9a 20 44.1b 19 43.3 b 20 13.22' ,78
Social functioning* 59.1 a 24 57.7 a 22 65.1 b 22 67.5b 22 5.16 bl ,49
Role-emotional 49,4 41 56.4 44 64.7 42 60.9 42 2.43 ,25
Mental health* 65.9a 17 68.8~ 18 74.2 b 15 71.2 b 16 8.90* .71

NOTE. Higher scores reflect better QOL. Means in the same row that do not share the same subscripts are significantly different ( p < .01) using
paired t tests. The energy conservation course was taught between weeks 7 and 13. Effect size (Cohen's d) for repeated-measures data 23 =
mean of week 7 - mean of week 13 ÷ the standard deviation x ~/2.
* Two participants had incomplete data.
* SF-36 subscales predicted to change as a result of the energy conservation course.
* p < .001.
II p < .01.

the 6 weeks after the course. The fourth subscale, role-physi- the participants implemented 6 or more energy conservation
cal, which was predicted to change as a result of the energy behaviors whereas 15% implemented 10 or more. After the
conservation course, approached (p = .08) but did not reach course, 82% implemented 6 or more energy conservation be-
the p < .05 level of significance. This result does not support haviors, as expected, and 35% implemented 10 or more. These
hypothesis 1. results are consistent with the study by Packer et al.4
There was no significant difference for time for 4 SF-36 Overall, participants reported implementing more energy
subscales: physical functioning, bodily pain, general health, conservation behaviors after the course (see table 5 for descrip-
and role-emotional, which were not expected to change as a tive data). The only energy conservation behavior that did not
result of the energy conservation course or the support group increase after the course was eliminating an activity entirely.
sessions (table 4). These results support hypotheses 2 and 3. It Energy conservation behaviors that were most frequently im-
should be noted, however, that the role-emotional subscale plemented after the course were changing body position for
approached (p = .07) but did not reach the level of signifi- certain activities, resting during longer activities, changing
cance. location of equipment/supplies, eliminating portions of activi-
ties, resting at least 1 hour daily, planning the day, and includ-
Energy Conservation Behavioral Change ing rest periods in the day. Packer 4 reported that participants in
The first 20 participants were given only the energy conser- their pilot study most frequently implemented many of the
vation behavioral change questionnaire after the energy con- same behaviors. Behaviors that were least frequently imple-
servation course. The remaining 34 participants completed the mented after the course were using adapted equipment, chang-
questionnaire before and after the course because it became ing the time of day of an activity, and using energy saving
clear that participants were using some energy conservation equipment. The behaviors that changed the most as a result of
principles before taking the course. Before the course, 38% of the course were identifying incorrect work heights, changing

Table 5: Energy Conservation Behavior Changes Before and After the Course (n = 34)*

Participants Implementing the Behavior Total Times Implemented

Before After Change Before After Change
Energy Conservation Behaviors n (%) n (%) n (%) n n n
Identified incorrect work heights 8 (23) 18 (52) +10 (55) 11 37 +26
Changed body position for certain activities 11 (32) 23 (68) +12 (52) 23 44 +21
Rested during longer activities 17 (50) 23 (67) +6 (26) 18 34 +16
Changed incorrect work heights 3 (8) 16 (47) +13 (81) 3 26 +23
Changed location of equipment/supplies 16 (47) 22 (64) +6 (27) 43 33 -10
Eliminated portions of activities 22 (64) 25 (73) +3 (12) 31 43 +12
Started using adapted equipment 7 (20) 11 (32) +4 (36) 12 17 +5
Changed the time of day of an activity 8 (23) 13 (38) +5 (38) 8 16 +8
Eliminated an activity entirely 16 (47) 16 (47) 0 (0) 22 24 +2
Rearranged a work area 12 (35) 17 (50) +5 (29) 23 23 0
Started using energy saving equipment 6 (17) 12 (35) +6 (50) 8 20 +12
Rested at least 1 hour daily 20 (59) 24 (70) +4 (16) 30 41 +11
Planned the day 19 (56) 31 (91) +12 (38) 27 50 +23
Included rest periods in the day 19 (55) 32 (94) +13 (40) 24 80 +56

* The first 20 participants took the test after the course. The remaining 34 participants took the tests before and after the course.

Arch PhysMed Rehabil Vol 82, April 2001

 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz 455

body position for certain activities, and changing incorrect energy conservation information was new, providing new strat-
work heights. Finally, there was a trend toward increased egies for fatigue management. For example, identifying and
frequency of energy conservation behaviors except for chang- changing incorrect work heights and using energy-saving
ing location of equipment and supplies and rearranging a work equipment were the behaviors least used before the course.
area. Once these behaviors are implemented, they do not need These behaviors showed a very high increase in frequency after
to be repeated. When asked what information was most helpful, the course, suggesting that the information was new and that
most reported planning their day and taking frequent rests. participants were willing to implement it. Second, the course
Most participants did not identify areas considered least help- effectively reinforced, supported, and increased current behav-
ful, but the few who did mentioned changing the way the body iors. For example, some behaviors most used before the course
is positioned for activities as least helpful. were planning the day, including rest during the day, and
resting during longer activities. These behaviors increased after
DISCUSSION the course, suggesting that participants found them effective
The study results support hypothesis 1, which predicted that and used them more frequently. Behaviors such as eliminating
a 6-week, community-based energy conservation course would tasks or portions of tasks and changing the location of equip-
be effective in reducing the impact of fatigue, increasing self- ment and supplies were common before the energy conserva-
efficacy, and improving some aspects of QOL for individuals tion course. The relatively small increase in these behaviors
with MS, The fact that these variables did not change signifi- after the course could be expected because they were imple-
cantly after control and no-intervention periods enhances the mented only once or twice, yet impact fatigue daily.
validity of the results. The more positive results of our study, That fatigue impact, self-efficacy, and QOL did not change
compared with earlier s t u d i e s , 4A6 a r e due in part to using a over the 6-week, no-intervention period supports hypothesis 2.
larger sample size, which increased the statistical power to Apparently, participants continued to practice the energy con-
detect change across time. It is speculated that the role-physi- servation behaviors in the 6 weeks after the course to maintain
cal and role-emotional subscales of the SF-36 might also have the positive benefits. Because MS is a progressive disease, the
reached statistical significance if an even larger sample size had fact that these variables did not change in the 6 weeks after the
been used. The fact that small effect sizes 23 were seen in these course indicates that the course had both immediate and short-
2 subscales (and in the physical functioning and general health term benefits. How long these benefits will last is unknown.
subscales) indicates that the course may affect these aspects of Future research will need to explore its long-term effects.
QOL, albeit in a lesser way. Although there were positive trends associated with the
A number of possible reasons explain why this energy con- support group (ie, control intervention) (tables 2-4), the fact
servation course was effective. We speculate that the use of a that there were no significant changes in the dependent vari-
group format reduced the isolation that many participants felt ables during the support group supports hypothesis 3. These
while fighting their fatigue problems by themselves. As mem- results provide strong evidence of the effectiveness of the
bers of each group bonded, it became a supportive environment energy conservation course because it controlled for the Haw-
for sharing their struggles and successes in fatigue manage- thorne effect and the fluctuating nature of MS. Because the
ment. Many personal stories supported the content of the control intervention came before the experimental intervention
course and reinforced the idea that if fatigue is managed better, for all participants, it is possible that the positive results were
it can make a difference in their lives. The group format caused by the cumulative effects of the support group and
reinforced the learning of energy conservation principles, en- course. In fact, there was concern while planning the study that
hanced creative problem solving, and supported energy con- the social function subscale on the SF-36 might improve sig-
servation behavioral change. Several participants mentioned nificantly during the support group. This did not happen and
receiving the most benefit from their interactions with group the fact that none of the dependent variables changed signifi-
members, and many participants continued to meet after the cantly during the support group suggests that the positive
study was completed. results were because of the course itself. This issue could be
The active learning activities used in the course enhanced the resolved more clearly in future studies by using a crossover
learning of the energy conservation principles by providing design.
practice in applying the principles to their lives. Because of the
nature of the 6-week course, there was opportunity to return to Limitations
the group and discuss what did and did not work. Participants For practical reasons, it was impossible to select participants
received positive feedback for their successes and encourage- randomly. Participants were self-selected, in that they re-
ment to try new strategies when others did not work. The sponded to an advertisement to participate. These individuals
opportunities to apply energy conservation principles during may have been more motivated to manage their fatigue and
and between sessions not only enhanced learning but also thus might have shown more positive results than a randomly
improved the participants' sense of self-efficacy for managing selected group. As a result, the study's results can be general-
fatigue (table 3) and increased the number of behaviors imple- ized only to individuals with MS motivated to participate in an
mented (table 5). However, what is not clear is whether im- energy conservation course. From a client-centered perspec-
proved self-efficacy enhanced the behaviors or whether using tive, 3j we believe that this is the optimal time to deliver an
the energy conservation behaviors and the resultant decreased energy conservation course (ie, when the clients decide they
fatigue impact enhanced self-efficacy. Future research will are ready to learn).
need to explore the relation between self-efficacy and behav- The screening criterion used to exclude persons with cogni-
ioral change. tive problems was based on a therapist's judgment. In retro-
The data in table 5 indicate that many participants were spect, the criterion was not adequate. Four participants admit-
using some energy conservation behaviors in their daily rou- ted to mild problems, but clearly had difficulty learning,
tines before participating in the course. Several things suggest remembering, and applying energy conservation principles.
that the course was effective in increasing energy conservation Eleven others admitted to mild cognitive problems but ap-
behaviors when individuals were already incorporating strate- peared to use compensatory strategies effectively. Because
gies in their lives. First, participants indicated that some of the only 4 participants had cognitive problems that appeared to

Arch Phys Med Rehabil Vol 82, April 2001

456 EFFICACY OF ENERGY CONSERVATION COURSE FOR MS, Mathiowetz

interfere with their learning, this variable probably had mini- 12. Hubsky EP, Sears JH. Fatigue in multiple sclerosis: guidelines for
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Arch Phys Med Rehabil Vol 82, April 2001