Effects of an Energy Conservation Course on Fatigue Impact
for Persons With Progressive Multiple Sclerosis
KEY WORDS
• fatigue management
• occupational therapy
• rehabilitation
Susan M. Vanage, MS, OTR, is Occupational Therapist,
Replay Physical Therapy, 1202 West Havens Street,
Kokomo, Indiana 46901; smvanage@yahoo.com.
Kirsten Kay Gilbertson, MS, OTR/L, is Occupational
Therapist, Mayo Clinic, Department of Physical Medicine
and Rehabilitation, Rochester, Minnesota.
Virgil Mathiowetz, PhD, OTR/L, FAOTA, is Associate
Professor, Program in Occupational Therapy, University of
Minnesota, Minneapolis, Minnesota.
The American Journal of Occupational Therapy
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Susan M. Vanage,
Kirsten Kay Gilbertson,
Virgil Mathiowetz
OBJECTIVE. Fatigue is a common, troublesome symptom for persons with multiple sclerosis. This study
evaluated the effects of an energy conservation course on fatigue impact for persons with multiple sclerosis
whose symptoms cause moderate to severe disability.
METHODS. Thirty-seven persons with progressive multiple sclerosis participated in an 8-week experimen-
tal energy conservation course treatment and an 8-week control period of traditional treatment using a
crossover design. The Fatigue Impact Scale (FIS) was used to assess fatigue impact before and after the exper-
imental and control periods, and 8 weeks post-energy conservation course.
RESULTS. After participation in the energy conservation course, the average FIS total score and physical,
cognitive, and psychosocial subscale scores decreased significantly, whereas the total and subscale scores did
not change significantly during the control period. Additionally, decreased fatigue impact was maintained 8
weeks after course completion for evaluated participants.
CONCLUSION. This study provides evidence that this energy conservation course can be a beneficial inter-
vention for persons with progressive multiple sclerosis.
Vanage, S. M., Gilbertson, K. K., & Mathiowetz, V. Effects of an energy conservation course on fatigue impact for persons
with progressive multiple sclerosis. American Journal of Occupational Therapy, 57, 315–323.
ultiple sclerosis is a neuromuscular disease characterized by symptoms includ-
M ing fatigue, spasticity, weakness, tremor, visual problems, and cognitive diffi-
culties (Schapiro, 1998). The range and scope of symptoms associated with multi-
ple sclerosis affect persons differently and are unpredictable (National Multiple
Sclerosis Society, 1999). However, fatigue is very common, troublesome, and
unique among persons with multiple sclerosis, and may negatively interfere with
daily functioning (Krupp, Alvarez, LaRocca, & Scheinberg, 1988) and occupa-
tional performance.
Although many studies have been conducted to investigate fatigue and its
impact on persons with multiple sclerosis, there is substantially less literature
regarding the efficacy of therapeutic interventions. For example, energy conserva-
tion education is an intervention commonly used by occupational therapists.
Regrettably, however, the Multiple Sclerosis Council for Clinical Practice
Guidelines (1998) reported that a “review of the MS [multiple sclerosis] literature
did not find any scientifically based evidence to establish the efficacy of this prac-
tice [energy effectiveness strategies]” (p. 27). Thus, there is a need for outcomes-
based research on energy conservation education for persons with disabilities sec-
ondary to fatigue problems, such as those that accompany multiple sclerosis.
Occupational therapists Packer, Brink, and Sauriol (1995) developed a course
entitled Managing Fatigue: A Six-Week Course for Energy Conservation, which was
designed for persons with fatigue due to a chronic illness. Mathiowetz, Matuska,
315
 and Murphy (2001) evaluated the efficacy of this energy
conservation course on 54 community-dwelling persons
with mild to moderate symptoms of multiple sclerosis.
According to the results, fatigue impact was significantly
reduced after participation in the course. In addition, 82%
of the participants implemented six or more energy conser-
vation behaviors. The purpose of this study was to deter-
mine whether similar results could be achieved for persons
with moderate to severe symptoms of multiple sclerosis.
Characteristics and Severity
of Fatigue Associated With
Multiple Sclerosis
Fatigue is reported to be the most common symptom asso-
ciated with persons with multiple sclerosis (Multiple
Sclerosis Council for Clinical Practice Guidelines, 1998),
occurring in about 80% of persons with multiple sclerosis
(National Multiple Sclerosis Society, March 2000). In addi-
tion to its high frequency, fatigue associated with multiple
sclerosis has also been found to be different from other
types of fatigue. Krupp et al. (1988) differentiated fatigue in
persons with multiple sclerosis from healthy adults, and
reported that persons with multiple sclerosis, more likely
than healthy persons, report that fatigue “(1) prevents sus-
tained physical functioning; (2) is worsened by heat; (3)
interferes with physical functioning; (4) comes on easily; (5)
interferes with meeting responsibilities; and (6) causes fre-
quent problems” (p. 436).
Fatigue renders many persons with multiple sclerosis
unable to perform various daily activities due to lack of effi-
ciency and endurance. Likewise, fatigue impedes an affect-
ed person’s ability to fully engage in desired occupational
performance and roles. Colosimo et al. (1995) reported
“the greatest difference [between fatigue in persons with
multiple sclerosis and healthy persons after intense exercise,
reduced sleep, or rest] is the impact on the activities of daily
living” (p. 353).
Packer, Sauriol, and Brouwer (1994) studied the severi-
ty of fatigue and its impact on persons with post-polio syn-
drome, chronic fatigue syndrome, and multiple sclerosis.
They found that each diagnostic group reported significant-
ly more fatigue and lower health status than that of the con-
trol group. They also reported that participation in energy-
demanding activities was reduced, especially so for the
multiple sclerosis and chronic fatigue syndrome groups.
Furthermore, they suggested that “intervention aimed at
developing skillful scheduling of rest periods, compensatory
skills, and lifestyle management may all prove helpful in
decreasing fatigue and improving activity profiles” (p. 1125).
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Energy Conservation Education
Packer et al. (1995) developed an energy conservation
course to guide occupational therapists who work with per-
sons who experience fatigue due to a chronic illness. The
principles presented throughout the course include: (a) the
value of rest; (b) budgeting and banking energy; (c) incor-
porating rest periods throughout the day; (d) learning to
communicate personal needs to others; (e) using good body
mechanics and posture; (f) using energy-efficient appliances
and organizing stations of activity; (g) separating fatiguing
tasks into components; (h) prioritizing and setting stan-
dards for activities; (i) planning rest periods with self-care,
productivity, and leisure activities so that a balance can be
maintained; and (j) reviewing course principles and setting
short-term and long-term goals.
To test the efficacy of the course, Packer et al. (1995)
conducted a pilot study (N = 16) with persons who experi-
enced fatigue secondary to chronic illnesses such as multi-
ple sclerosis, post-polio syndrome, chronic fatigue syn-
drome, and fibromyalgia. Packer et al. used the Fatigue
Severity Scale (Krupp, LaRocca, Muir-Nash, & Steinberg,
1989) and the Fatigue Impact Scale (FIS) (Fisk, Pontefract,
Ritvo, Archibald, & Murray, 1994) assessments before and
after the course to measure fatigue and reported “positive
trends for all measures and statistically significant changes
(p < 0.05) on the physical domain measure of the FIS
[Fatigue Impact Scale]. With a larger sample size and
increased statistical power, significance is expected on the
other domains” (p. 7). In addition, over 80% of the 16 par-
ticipants had implemented at least six positive energy con-
servation behavioral changes at the end of the course
(Packer et al.).
Mathiowetz et al. (2001) evaluated the effect of the 6-
week energy conservation course (Packer et al., 1995) upon
fatigue impact, self-efficacy, and quality of life for individu-
als with multiple sclerosis (N = 54). They reported that
fatigue impact decreased, as measured by the FIS, self-effi-
cacy increased, and the quality of life improved for the
course participants after completion of the course
(Mathiowetz et al.). Results from this study strongly sup-
port the efficacy of the energy conservation course in reduc-
ing fatigue impact for persons with mild to moderate symp-
toms associated with multiple sclerosis. Occupational
therapy practitioners, however, often treat persons with
multiple sclerosis when they experience disabling (i.e.,
moderate to severe) symptoms. It is vital that research be
conducted to investigate, and then demonstrate, the relia-
bility and efficacy of treatments, such as energy conserva-
tion. At the time of the study there was no research describ-
ing the efficacy and effectiveness of an energy conservation
May/June 2003, Volume 57, Number 3
 course for persons with more disabling symptoms associat-
ed with multiple sclerosis.
Purpose
The specific purpose of this study was to evaluate the effects
of the energy conservation course developed by Packer et al.
(1995) on fatigue impact for persons with progressive mul-
tiple sclerosis who experience moderate to severe disability.
If the course was found to be effective, it would increase the
confidence level of claiming that the course is a beneficial
intervention for persons with progressive multiple sclerosis.
Three hypotheses were proposed: (1) participants in
the energy conservation course would report significantly
less fatigue impact following course completion compared
to participants receiving only traditional treatment when
using the initial score of the FIS as a covariate; (2) all par-
ticipants in the energy conservation course would report a
significant reduction in fatigue impact immediately follow-
ing course completion; and (3) there would be no signifi-
cant difference in fatigue impact scores reported 8 weeks
post-energy conservation course compared to immediate
post-energy conservation course scores (i.e., effects of the
course would be maintained).
Methods
Design
This quasi-experimental study incorporated experimental
and control conditions; participants were not randomly
assigned to groups as existing groups were used for conve-
nience. The crossover design used in this study counter-bal-
anced the experimental and control treatment conditions
(see Table 1) (Portney and Watkins, 2000). The experimen-
tal condition consisted of the energy conservation course,
while the control condition consisted of the traditional sup-
port group led by a chaplain at the center. Group A received
the experimental condition (energy conservation course) for
the first 8 weeks, followed by 8 weeks of the control condi-
tion (support group). Group B received the control condi-
Table 1. Crossover Research Design Used in the Study.
Group A: O1 X1 O2 X2 O3
Group B: O1 X2 O2 X1 O3 X2 O4
Note. O = Fatigue Impact Scale administered; X1 = Experimental condition
(energy conservation course); X2 = Control condition (support group)
The Measuring Change assessment was administered in the Observation (O)
after X1.
The American Journal of Occupational Therapy
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tion (support group), followed by 8 weeks of the experi-
mental condition (energy conservation course). Following
the course, both groups resumed attendance with the sup-
port group, and all Group A members and most Group B
members completed the FIS to determine if changes in
fatigue levels were maintained 8 weeks post-energy conser-
vation course. Groups A and B were each comprised of four
subgroups.
Participants
Thirty-seven persons who regularly attended a community-
based, maintenance rehabilitation center for persons with
progressive multiple sclerosis volunteered to participate in
this study and met the entrance criteria. Specifically, all par-
ticipants were diagnosed with multiple sclerosis and scored
5.5 or higher on the Expanded Disability Status Scale
(Kurtzke, 1983). Persons with a score of 5.5 were “ambula-
tory without aid or rest for about 100 meters” and had “dis-
ability severe enough to preclude full daily activities”
(Kurtzke, p. 1451). Cognition was assessed using the
Learning Potential subtest from the Rehabilitation Institute
of Chicago Functional Assessment Scale, Version IV
(Rehabilitation Institute of Chicago, 1996). Participants
with a score of 4 or above on the 7-point scale were includ-
ed. A score of 4 indicated mild to moderate learning diffi-
culties with “the ability to acquire the skills addressed in
rehabilitation therapies and to incorporate them into activ-
ities of daily living” (Rehabilitation Institute of Chicago,
1996, p. 22). The occupational therapist and/or the certi-
fied occupational therapy assistant employed at the center
provided cognition assessments, as they were familiar with
the participants. Fatigue was assessed using the Fatigue
Severity Scale (Krupp et al., 1989). To be included in the
study, participants had to score 4 or higher on the 7-point
scale, indicating moderate to strong agreement with nine
fatigue severity statements.
Exclusion criteria included missing three or more of the
eight energy conservation course sessions or experiencing
cognitive difficulty to such a degree that the person could
not adequately learn course material. Data from seven vol-
unteer participants were excluded for the following reasons:
(a) three persons missed three or more sessions; (b) one per-
son was hospitalized and missed consecutive testing dates
after the course; (c) one person was in the midst of an exac-
erbation and had recently changed medications, which
compromised his cognition; (d) one person withdrew from
the energy conservation course after the first session due to
depression, which interfered with cognition; and (e) one
person decided not to participate in the energy conservation
course for unknown reasons.
317
 Identified characteristics of the participants included Table 2. Characteristics of Energy Conservation Course Participants
sex, race, method of mobility, age, time since diagnosis, and for Each Group and Total Sample (N = 37).
Group A Group B Total
scores from the Fatigue Severity Scale (Krupp et al., 1989) n % n % n %
and the Learning Potential Assessment (Rehabilitation Gender
Institute of Chicago, 1996) (see Table 2). All study partici- Men 4 19 4 25 8 22
Women 17 81 12 75 29 78
pants were Caucasian and needed some type of mobility
Method of Mobility
device. Independent t tests conducted on the various char- Power wheelchair 8 38 9 56 17 46
acteristics showed no significant differences between Manual wheelchair 5 24 1 6 6 16
3-Wheel scooter 8 38 6 38 14 38
Groups A and B relative to these variables. A chi-square test Other Variables*
performed on the gender factor also showed no significant Age (years) 56.3 (10.5) 54.7 (10.5) 55.6 (10.3)
Years since diagnosis 18.7 (8.3) 22.1 (8.3) 20.2 (8.3)
differences between groups. These results indicated that
Fatigue Severity Scale Score 5.3 (.9) 5.3 (.9) 5.3 (.9)
Groups A and B were equivalent, thus group differences in Learning Potential Score 5.3 (.7) 4.8 (.8) 5.1 (.8)
the findings would not be affected by these characteristics. *Data presented as mean (SD)

Energy Conservation Course
The independent variable in this study was the energy con-
servation course developed by Packer et al. (1995), a 6-week
course for persons for whom fatigue is a secondary symp-
tom to chronic illnesses, including multiple sclerosis. The
course “is primarily aimed at reducing disability by increas-
ing an individual’s ability to participate in those self-care,
productive, and leisure activities that are self-identified as
important, meaningful, or necessary” (Packer et al., p. 2).
The course was modified to meet the unique needs of
the study participants who were more severely disabled than
participants in previous studies (Packer et al., 1995;
Mathiowetz et al., 2001). For example, the course was
taught in 1-hour segments instead of the recommended 2-
hour segments to accommodate for the decreased attention
span and increased fatigue of participants, and the schedul-
ing limitations of the center. To compensate for the shorter
session lengths, the number of course sessions was increased
from six to eight. However, the net result of these modifi-
cations was that the actual time in the energy conservation
course was a total of 8 hours instead of the recommended
12 hours. In addition, there were fewer participants in each
group—three to eight persons—as compared to the sug-
gested group size of 8 to 10 persons (Packer et al.) to com-
pensate for the higher disability level of the study sample.
Although one of the sessions contained information regard-
ing good sitting, standing, and walking postures, only sit-
ting postures were discussed since participants were func-
tionally non-ambulatory, thus making discussion of the
other postures irrelevant. Study participants did not write
answers to the homework assignments, as suggested in the
original course (Packer et al.), due to their fatigue and
inability to write well secondary to poor coordination.
Instead, participants were encouraged to think about the
homework assignment and discuss their thoughts at the
next session. Two entry-level graduate occupational therapy
students and the certified occupational therapy assistant
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working at the center taught the eight energy conservation
sessions that comprised each course.
Measurement Tools
Several measurement tools were employed throughout this
study. During the screening process, the Learning Potential
assessment from the Rehabilitation Institute of Chicago
Functional Assessment, Version IV (Rehabilitation Institute
of Chicago, 1996), was used to determine if volunteers had
sufficient cognition to benefit from the course. The
Learning Potential assessment consists of seven cognitive
levels to describe a person’s ability to apply skills learned
during rehabilitation into daily living activities. No reliabil-
ity or validity data were reported for this assessment.
The Fatigue Severity Scale (Krupp et al., 1989) was also
used during the screening process to determine fatigue level.
The Fatigue Severity Scale consists of nine statements that
are scored from 0 to 7, with a score of 7 indicating a strong
agreement with the fatigue statement and 0 indicating
strong disagreement. In a study of persons with multiple
sclerosis, systemic lupus erythematosus, and healthy per-
sons, Krupp et al. reported that the Fatigue Severity Scale
demonstrated strong internal consistency among individu-
als with multiple sclerosis (Cronbach’s α = .81), as well as
for the entire sample population (Cronbach’s α = .88); high
test–retest reliability (r = .84); and good discriminant valid-
ity (i.e., able to separate persons with multiple sclerosis or
systemic lupus erythematosus from healthy persons).
The FIS (Fisk, Pontefract, et al., 1994) was selected to
measure the dependent variable, fatigue impact, because of
the large number and variety of fatigue impact questions.
The FIS is a 40-item, self-report questionnaire that gives a
total score as well as scores for each subscale—physical, cog-
nitive, and psychosocial. Participants rate each of 40 items
on a scale ranging from 0 (“No problem”) to 4 (“Extreme
problem”). The Fatigue Guidelines Development Panel
(Multiple Sclerosis Council for Clinical Practice
May/June 2003, Volume 57, Number 3
 Guidelines, 1998) “selected the 40-item FIS as most appro-
priate for assessing the impact of MS [multiple sclerosis]-
related fatigue on quality of life” (p. 2).
The FIS was assessed with 85 persons with multiple
sclerosis and 20 persons with hypertension. With the
responses from both groups included, the FIS was found to
have a strong internal consistency (Cronbach’s α > .93)
(Fisk, Pontefract, et al., 1994). In a follow-up study, the FIS
was assessed with persons with chronic fatigue syndrome,
multiple sclerosis, and hypertension (Fisk, Ritvo, Ross,
Haase, Marrie, & Schlech, 1994). Results from that study
suggested that the FIS offers good discriminant validity and
strong internal consistency (Cronbach’s α > .87).
Mathiowetz (in press) reported that the test–retest reliabili-
ty for the FIS for persons with multiple sclerosis (i.e., intra-
class correlation coefficient = .81–.85 for cognitive and psy-
chosocial subscales, and total score, was good [Portney &
Watkins, 2000]). However, the intraclass correlation coeffi-
cient for the physical subscale was .69, slightly lower than
desired. Mathiowetz recommended using the physical sub-
scale with caution.
The Measuring Change assessment, developed by
Packer et al. (1995), was administered after the energy con-
servation course. The assessment consists of 14 statements
regarding behaviors to reduce fatigue impact (e.g., rested at
least 1 hour total per day). The purpose of the assessment
was to record behavioral changes adopted as a result of
implementing energy conservation techniques learned in
the course. No reliability or validity data were reported for
this assessment.
Procedure
After the Institutional Review Board’s approval, the center’s
certified occupational therapist assistant and occupational
therapist recruited members who attend the center
Monday, Tuesday, Wednesday, Friday, and Saturday for par-
ticipation in the study. Interested members completed the
Fatigue Severity Scale (Krupp et al., 1989) assessment and
were scored on the Learning Potential assessment
(Rehabilitation Institute of Chicago, 1996) by the occupa-
tional therapist or the certified occupational therapy assis-
tant or both. If volunteers’ scores from these screenings met
the inclusion criteria and potential participants signed a
consent form, they were placed in groups according to the
day they attended the center. (In total, eight energy conser-
vation courses were taught. Since course instruction did not
occur simultaneously, course instruction and subsequent
data collection occurred over the period of about 1 year.)
After consent, participants completed the FIS assess-
ment (Fisk, Pontefract, et al., 1994) to obtain pre-energy
conservation course (for Group A) and pre-control period
The American Journal of Occupational Therapy
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(for Group B) fatigue impact scores. The graduate students,
and the center’s occupational therapist and certified occu-
pational therapy assistant administered the FIS by recording
participants’ oral responses because most participants had
difficulty completing the questionnaires due to fatigue or
incoordination. After the first 8-week period, the FIS was
again administered to both groups. Group A members also
completed the Measuring Change assessment. Since admin-
istration of the assessments was time-consuming, it was
scheduled for the week after completion of the 8-week
course (i.e., week #9).
After FIS assessments were completed for the first 8-
week period, participants in Group B participated in the
energy conservation course while Group A members partic-
ipated in the traditional, control treatment. After the second
8-week period, Groups A and B were given the FIS for the
third time. Group B members also completed the Measuring
Change assessment at this time. The third FIS for Group A
members served to measure fatigue levels 8 weeks after com-
pletion of the energy conservation course. In order to obtain
the same information for Group B members, the FIS was
administered a fourth time, to Group B members only, 8
weeks after completion of the energy conservation course.
Because retrieving 8-week post-energy conservation fatigue
impact information was not part of the original study’s
design and was added into the study protocol midway
through, eight members from Group B did not complete 8-
week, post-energy conservation course FIS scores.
Due to circumstances beyond our control, the FIS and
Measuring Change assessments could not always be admin-
istered when scheduled. All participants completed the pre-
study FIS assessment within the week before attending the
first session of the energy conservation course. The second
FIS and Measuring Change assessments were completed by
all Group A members on the scheduled date, with the
exception of one member who completed the two assess-
ments the same day as course completion in anticipation of
an intended absence the following week. Due to severe
weather and unexpected closing of the center, 13 members
of Group A did not take the third FIS at the scheduled
time. The 2 weeks following the scheduled date were win-
ter holidays at the center, which resulted in nine members
taking the FIS 3 weeks late, three members taking it 4
weeks late, and one member taking it 5 weeks late. It should
be noted that this extended the third FIS (8-week, post-
energy conservation course) assessment date and results
indicated that the effects of the energy conservation course
were still maintained even longer than the scheduled 8
weeks, post-energy conservation course.
All members of Group B, except one, completed the
pre-energy conservation course FIS within 1 week prior to
319
 participation in the energy conservation course. One mem- Table 3. Descriptive Statistics on Subscale and Total FIS Scores
ber, due to absences and an oversight from the evaluator, for Group A and Group B Participants for the Initial 8 Weeks and
Analysis of Covariance Between Groups A and B on 8-Week
completed the pre-energy conservation course FIS 3 weeks Scores Using Initial Scores as the Covariate.
late. All Group B members completed the second FIS with- Initial Scores 8-Week Scores
in 1 week prior to the energy conservation course. A total FIS Groupa M (SD) M (SD) df F(1, 36)
of five Group B members completed the third FIS and Cognitive A 15.7 (8.9) 10.8 (7.7) 1 4.44*
B 18.2 (9.5) 16.9 (10.8)
Measuring Change assessment late: three persons complet- Physical A 23.6 (5.9) 17.9 (7.1) 1 5.39*
ed them 2 weeks late, one completed them 3 weeks late, B 21.9 (9.4) 21.8 (9.8)
Psychosocial A 33.2 (14.1) 24.3 (13.5) 1 8.34**
and another 4 weeks late due to absences and winter holi-
B 37.0 (18.5) 38.1 (20.0)
day at the center. Seven out of eight Group B members for Total A 72.5 (25.7) 53.0 (25.8) 1 8.02**
whom it was scheduled completed the fourth FIS. B 77.1 (34.8) 76.8 (38.5)
aGroup A (n = 21) participated in the energy conservation course; Group B

Data Analysis (n = 16) participated in support group as part of traditional treatment.

Parametric statistics were used to analyze the results of this
study because the data followed a normal distribution and
had low skewness and kurtosis values. All data related to
FIS scores, except effect size, were machine-calculated using
version 9.0 of the Statistical Package for the Social Sciences
software for Windows. Subscales and total FIS data were
examined using the analysis of covariance (ANCOVA)
method, determining the between-groups effects (experi-
mental vs. control), using the initial scores as the covariate
(Portney & Watkins, 2000).
In addition, a one-sample t test was run using pooled
data (i.e., Group A and B data combined) to determine sig-
nificance in FIS change scores at various times throughout
the study. Specifically, the change in FIS scores between pre-
energy conservation course (taken immediately before the
energy conservation course) and post-energy conservation
course #1 (taken immediately after completion of the ener-
gy conservation course) were compared. Further, the
change in FIS scores between post-energy conservation
course #1 and post-energy conservation course #2, collect-
ed 8 weeks after completion of the course, were compared.
The effect size (Cohen’s d) (Portney & Watkins, 2000) was
manually calculated for each of the FIS subscales and total
score to help determine the clinical significance of the
results.
The data from the Measuring Change assessment were
analyzed descriptively. Each of the 14 fatigue-behavioral
items was tallied according to positive or negative frequency
of response. The number of participants indicating change
and an overall percentage of changes were reported.
*p < .05. **p < .01.
FIS = Fatigue Impact Scale
members who participated in the support group as part of
traditional treatment (see Table 3). The FIS scores for
Group A members decreased (i.e., represented less fatigue
impact) in each subscale and total score after completing
the energy conservation course, while the Group B FIS
scores changed minimally during the first 8 weeks of the
study. Results from the ANCOVA suggest a significant dif-
ference in the cognitive, physical, and psychosocial sub-
scales, and total FIS scores, between Groups A and B (see
Table 3). These results support hypothesis #1, which pre-
dicted a significant difference in fatigue impact between
control and experimental groups.
When the data from Groups A and B were combined,
the FIS total score and all subscale scores for all participants
decreased between pre-energy conservation course and
post-energy conservation course #1 assessments (see Table
4). In addition, the decrease in FIS scores reported imme-
diately post-energy conservation course was maintained 8
weeks after completion of the course (i.e., post-energy con-
servation course #2).
Using a one-sample t test, FIS change scores between
the pre-energy conservation course and post-energy conser-
vation course #1 were significant for each of the subscales
and the total score (see Table 5). This indicated a reduction
in fatigue impact after the energy conservation course, as
Table 4. Descriptive Data for the Three Subscales and Total Score
of the FISa for All Persons (Groups A and B, N = 37b).
FIS Subscales Pre-EC Course Post-EC Course #1 Post-EC Course #2
and Total Score M (SD) M (SD) M (SD)

Results Cognitive
Physical
16.2
22.8
(9.6)
(7.8)
12.2 (8.1)
18.6 (8.2)
12.2 (7.5)
18.8 (9.0)
Descriptive statistics were computed for each FIS subscale Psychosocial 35.3 (16.8) 27.8 (15.8) 27.0 (16.8)

as well as the total score for Group A and B members at the Total 74.3 (31.4) 58.6 (30.0) 57.4 (31.3)
a
Lower scores reflect a decreased impact of fatigue.
beginning and end of the first 8 weeks of the study. This b
N = 28 Available for Post-EC Course #2.
provided a comparison between Group A members who FIS = Fatigue Impact Scale
participated in the energy conservation course and Group B EC = Energy conservation

320 May/June 2003, Volume 57, Number 3

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 Table 5. Means and Standard Deviations of Difference Scores Table 6. Number and Percentage of Participants Implementing
Between Various Assessment Timesa, One-Sample t Tests for All Energy Conservation Behavior Changes After the Energy
Subjects (N = 37b) and Cohen’s d Effect Sizes. Conservation Course (N = 37).
FIS M (SD) df t d Energy Conservation Behaviors n (%)
Pre-EC Course vs. Post-EC Course #1 Identified ergonomically-poor work heights 23 (62%)
Cognitive 4.0 (6.8) 36 3.6* .82 Changed body position when performing certain activities 25 (68%)
Physical 4.2 (7.9) 36 3.2* .75
Rested throughout activities lasting 30 minutes or longer 23 (62%)
Psychosocial 7.5 (12.7) 36 3.6* .83
Changed ergonomically-poor work heights 16 (43%)
Total 15.7 (25.0) 36 3.8* .89
Moved the location of equipment or supplies 18 (49%)
Post-EC Course #1 vs. Post-EC Course #2
Cognitive -.4 (7.2) 27 -.3 -.08 Omitted part of an activity or had someone else do it 24 (65%)
Physical 1.0 (8.1) 27 .6 .17 Initiated the use of adaptive equipment 12 (32%)
Psychosocial 1.0 (13.3) 27 .4 .11
Performed an activity at a different time of day 15 (41%)
Total 2.1 (23.7) 27 .5 .13
Omitted an activity entirely, or had someone else do it 11 (30%)
aPre-EC Course scores were those recorded prior to the course. Post-EC
Changed the outlay of a work area 19 (51%)
Course #1 scores were recorded immediately following the completion of the
course. Post-EC Course #2 scores were recorded 8 weeks after the comple- Initiated the use of energy-saving equipment 8 (22%)
tion of the course. Rested at least 60 minutes daily 16 (43%)
b
n = 28 Available for Post-EC Course #2. Planned the day’s events 21 (57%)
*p < .01. Incorporated rest breaks throughout the day 26 (70%)
FIS = Fatigue Impact Scale
Note: From Managing fatigue: A six-week course for energy conservation
EC = Energy conservation (Therapist worksheet 6.2), by T. L. Packer, N. Brink, and A. Sauriol, 1995,
Tucson, AZ: Therapy Skill Builders. Copyright 1955 by T. L. Packer. Adapted
with permission of the author.
predicted by hypothesis #2. In contrast, FIS change scores
between post-energy conservation course #1 and post-ener-
gy conservation course #2 scores were not significant. This questions. It is speculated that some participants were
suggests that the decrease in fatigue impact observed post- already engaging in these fatigue-reducing behaviors prior
energy conservation course #1 was maintained 8 weeks after to the course, and thus hadn’t changed their behavior. On
completion. This result supports hypothesis #3. the other hand, it might not have been physically possible
In addition, Cohen’s d values for all participants suggest for some participants to adopt a fatigue management
that there were medium to large effect sizes (Portney & behavior, such as rearranging a work area, without the assis-
Watkins, 2000) between pre-energy conservation course tance of another person. For all participants, 84% made at
and post-energy conservation course #1 (see Table 5). This least four changes, 78% made at least five changes, and
suggests that the differences between pre- and post- energy 70% made at least six changes.
conservation scores were substantial. In contrast, there were
very small effect sizes between scores taken at post-energy
conservation course #1 and post-energy conservation course Discussion
#2, as expected (see Table 5). This indicates that the decreas- After combining the data from all participants, all FIS
es in fatigue impact were maintained from completion of scores were significantly reduced after completion of the
the course to 8 weeks after the energy conservation course. energy conservation course. These data support hypothesis
One goal for this course was that participants would #2, which predicted there would be a significant reduction
make behavioral changes in their management of fatigue. of fatigue impact in the physical, cognitive, psychosocial
The Measuring Change assessment was used to assess such subscales, and total score of the FIS after participating in the
changes (see Table 6). The results indicated that the partic- energy conservation course. It was surprising the effect sizes
ipants’ most notable changes were: (a) incorporating rest in this study (d = .75–.89) were larger than the effect sizes
breaks throughout the day (70% of participants made the in the Mathiowetz et al. (2001) study (d = .53–.69). This
change); (b) changing body position when performing cer- difference implies that this energy conservation course
tain activities (68%); (c) omitting part of an activity or hav- might be even more effective for persons with moderate to
ing someone else do it (65%); (d) resting throughout activ- severe disabilities than for those with mild to moderate dis-
ities lasting 30 minutes or longer (62%); and (e) identifying abilities. Thus, therapists should not assume that individu-
ergonomically-poor work heights (62%). Behavioral als with moderate to severe disabilities have learned energy
changes made by the lowest percentage of participants conservation strategies out of necessity and therefore could
included initiating the use of energy-saving equipment not benefit from this course.
(22%) and omitting an activity entirely (30%). The reason The analysis using one-sample t tests suggested that
for these low percentages may be due to the wording of the there was no significant difference in fatigue impact
The American Journal of Occupational Therapy 321
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 between immediate post-energy conservation course and 8-
week post-energy conservation course measurements. As
hypothesis #3 had predicted, the effects of the energy con-
servation course were maintained 8 weeks after the course
was completed. This critical finding indicates that behav-
ioral changes made as a result of the course became incor-
porated into daily routines and had an ongoing effect on
the impact of fatigue in daily functioning. This also suggests
that persons with moderate to severe disability can learn
and maintain new energy conservation behaviors at least 8
weeks after the course. A follow-up study is needed to deter-
mine whether these positive effects are maintained long-
term as well.
The results of the Measuring Change assessment indi-
cate that 70% of participants made at least six behavioral
changes. This percentage is not as high as that of
Mathiowetz et al. (2001) who found that 82% of partici-
pants with mild to moderate symptoms associated with
multiple sclerosis made at least six behavioral changes as a
result of the course. Packer et al. (1995) also found that over
80% of the participants in their pilot study implemented
six of the changes. This difference in reported behavioral
changes may be due to persons in this study already having
made changes to their fatigue-related behaviors due to prior
education or lifestyle necessity. Most individuals in this
study had lived with multiple sclerosis for many years, an
average of 20 years since diagnosis. In contrast, the average
time since diagnosis for participants in the Mathiowetz
et al. study was 9.5 years. The difference in time post-
diagnosis may have played a role in the behavioral change
discrepancy.
Course topics that seemed particularly relevant and
interesting to group members included the importance of
rest and planning rest periods into each day, communica-
tion with others regarding fatigue and its effects, design of
work stations, and incorporation of proper sitting postures.
Many responded positively toward the concept of resting
before becoming fatigued. On the other hand, the topic of
balancing schedules did not apply for the majority of par-
ticipants. Many indicated that although they would like to
control their schedules, they had to rely on other people
(i.e., home health aids, spouses, children, etc.) to assist them
with daily activities and thus were often not in control of
daily scheduling.
Group dynamics may have contributed to the positive
outcome of this study and the significant reduction in social
fatigue. Group members knew each other reasonably well
because they regularly attended the center the same day
each week. They seemed to feel comfortable and enjoy the
interaction with each other, and eagerly participated in
group discussions, especially as the course progressed. This
322
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supportive group environment fostered a feeling of group
unity and acceptance. Perhaps the positive social environ-
ment, in addition to reducing psychosocial fatigue impact,
provided the foundation and catalyst for changes in fatigue
management behavior and the ultimate significant reduc-
tion in overall fatigue impact. It seemed that fostering a
supportive group environment was an important factor to
the success of this program.
Study Limitations
Participants and evaluators were not blind to group assign-
ments. The participants may have wanted to help the
researchers and the study. Therefore, when they were
administered the FIS by the researcher, occupational thera-
pist, or certified occupational therapy assistant, participants
may have subconsciously altered their responses about
fatigue impact, particularly immediately after completion
of the course. (In the study by Mathiowetz et al., 2001,
the instructors also administered the assessments, but
participants filled out their own assessments.) In future
studies, the person administering the assessments should be
blind to group assignment and not be involved in course
instruction.
Study volunteers were selected from among active
members of the center and group assignment was nonran-
dom, based conveniently on participants’ scheduled day for
attending the center, which may have led to a biased sam-
ple. To achieve greater randomness, future research should
incorporate random group assignment and selection of par-
ticipants from a more diverse population to incorporate
greater differences in ethnic background and geographical
location.
The certified occupational therapy assistant took a
leave of absence from the center during the latter part of the
yearlong data collection, leaving during midcourse.
Although this may have altered group dynamics, the posi-
tive results of this study suggest that this change did not
appear to negatively affect the outcome of the study.
Reliability and validity data were not available for the
Learning Potential and Measuring Change assessments.
Sufficient reliability and validity data for these assessments
would have increased the confidence level of the validity of
those parts of this study.
Conclusion
The expectation that this energy conservation course would
contribute to a reduction in the impact of fatigue among
persons with progressive multiple sclerosis was fully sup-
ported by this study. The individuals in the control group
May/June 2003, Volume 57, Number 3
 who received the support group as part of traditional treat-
ment at the center did not experience a reduction in fatigue
impact. Therefore, the reduction in fatigue impact can be
attributed strongly to the energy conservation course. The
energy conservation course has been shown to be an effec-
tive tool for the management of fatigue in individuals with
mild to moderate symptoms associated with multiple scle-
rosis (Mathiowetz et al., 2001) and now is demonstrated to
be effective with persons who experience moderate to severe
effects of progressive multiple sclerosis. Based on the results
of this study, the modified energy conservation course is
recommended as an effective therapeutic intervention for
people with progressive multiple sclerosis. ▲
Acknowledgments
The authors thank Valerie Carter, COTA, for assistance
with participant recruitment, screening, and instruction,
and Peggy Mueller, OTR/L, for assistance with participant
recruitment and screening. This study was undertaken by
the first two authors in partial fulfillment of the require-
ments for the Master of Occupational Therapy degree from
the University of Minnesota, Minneapolis, Minnesota.
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