Rebecca Cunningham OTD, OTR/L, MSCS
Associate Director for Lifestyle Redesign® Continuing Education and Certification, and Assistant Professor of Clinical Occupational Therapy
Rebecca Cunningham received her master’s and doctorate of occupational therapy degrees from the University of Southern California. Her clinical residency was completed at the USC Occupational Therapy Faculty Practice, where she provided Lifestyle Redesign services and focused on further development of the Lifestyle Redesign program for individuals living with Multiple Sclerosis. As a clinical faculty member at the USC Occupational Therapy Faculty Practice, Dr. Cunningham works with clients in the Multiple Sclerosis, chronic pain and headaches and mental health programs, and is a member of the USC Multiple Sclerosis multidisciplinary team.
Doctorate of Occupational Therapy (OTD)
2016 | University of Southern California
Master of Arts (MA)
in Occupational Therapy
2015 | University of Southern California
Bachelor of Arts (BA)
2008 | University of California, San Diego
Cunningham, R., Uyeshiro Simon, A., & Preissner, K. (2022). Occupational therapy practice guidelines for adults with multiple sclerosis. American Journal of Occupational Therapy, 76(5), 7605397010. https://doi.org/10.5014/ajot.2022.050088 Show abstract
Importance. Occupational therapy practitioners play an important role in addressing the occupational performance and participation needs of adults with multiple sclerosis (MS) and their caregivers.
Objective. This Practice Guideline aims to help occupational therapy practitioners, as well as the people who manage, reimburse, or set policy regarding occupational therapy services, understand occupational therapy’s role in providing services to adults with MS and their caregivers. This guideline can also serve as a reference for health care professionals, health care managers, educators, regulators, third-party payers, managed care organizations, and researchers.
Method. We examined, synthesized, and integrated the results of four systematic reviews into clinical recommendations. Three systematic reviews specified occupational domains as outcomes of interest, and one focused on interventions for caregivers of people with MS.
Results. Twenty-one articles from the systematic reviews with strong or moderate strength of evidence served as the basis for the clinical recommendations.
Keywords. adult, multiple sclerosis, occupational therapists, practice guidelines, sleep, systematic reviews, caregivers, clients, health, fatigue
Cunningham, R., & Gan, K. (2022). Occupational therapy interventions for job retention for individuals with multiple sclerosis: A case study. International Journal of MS Care, 24(S1), 68. https://doi.org/10.7224/1537-2073-24.s1.1 Show abstract
Background. In the United States, although approximately 66% of individuals with MS are working at the time of their diagnosis, only approximately 20% are employed 10 years after their diagnosis. Approximately 75% of individuals with MS voluntarily leave work before symptoms make them incapable of work. Research shows that individuals with MS who are unemployed experience higher levels of perceived stress than their employed counterparts. There is inconclusive evidence to support vocational rehabilitation (VR) for individuals with MS, highlighting gaps in traditional VR services. Nevertheless, studies highlight the importance of multidisciplinary care to keep this population in the workforce. The unemployment trends for individuals with MS showcases the need to address both functional and psychological aspects of returning to and/or maintaining employment. Occupational therapy (OT) practitioners can support individuals with MS in navigating the common barriers to employment, including obtaining reasonable work accommodations, understanding workplace protections under the Americans with Disabilities Act (ADA), managing physical symptoms secondary to MS, self-advocacy, and processing socioemotional concerns with symptom management in the workplace.
Objectives. Delineate the delivery of interventions to support job retention in patients with MS and provide a case study with clinical outcomes to demonstrate how these interventions can be integrated into an OT plan of care.
Methods. The patient participated in 7 sessions over the OT plan of care. The following interventions were used to support work engagement: symptom management training, education regarding ADA protections, reasonable work accommodations, and addressing socioemotional concerns with symptom management in the workplace. The Canadian Occupational Performance Measure (COPM) was administered before and after the implementation of the plan of care to capture perceived performance and satisfaction in areas of occupational performance deficit.
Results. Clinically significant improvement occurred in the COPM performance (+3.0) and satisfaction (+5.0) scores for the work-specific domain. In addition, the patient showed clinically significant improvement in the aggregate scores, with a 3.2-point increase in performance and a 4.4-point increase in satisfaction. Qualitatively, the patient reported increased self-efficacy with work and job retention and improved management of symptoms in the work context.
Conclusions. This case study highlights interventions that OT practitioners can use to address the occupational domain of work and contributes to the literature supporting OT involvement in supporting job retention for individuals living with MS.
Uyeshiro Simon, A., & Cunningham, R. (2022). Interventions for instrumental activities of daily living in adults with multiple sclerosis. American Journal of Occupational Therapy, 76(2), 7602390010. https://doi.org/10.5014/ajot.2022.049473 Show abstract
Evidence Connection articles provide examples of how evidence from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Project can be directly translated into clinical practice. These articles present a summary of the topic and case studies that demonstrate how the evidence from these reviews can inform clinical decision making. This Evidence Connection article includes findings from a systematic review of interventions within the scope of occupational therapy practice that improve or maintain performance of or participation in instrumental activities of daily living for people living with multiple sclerosis.
Keywords. adult, health, multiple sclerosis, systematic reviews, treatment goals, cognitive-behavioral therapy
Cunningham, R., & Uyeshiro Simon, A. (2022). Interventions for instrumental activities of daily living among adults with multiple sclerosis: A systematic review. American Journal of Occupational Therapy, 76(2), 7602205130. https://doi.org/10.5014/ajot.2022.049092 Show abstract
Importance. Occupational therapy practitioners need updated information about interventions that may improve or maintain functional changes in instrumental activity of daily living (IADL) engagement caused by multiple sclerosis (MS).
Objective. To conduct a narrative synthesis of updated evidence on interventions within the scope of occupational therapy to improve or maintain performance of and participation in IADLs among adults with MS.
Data Sources. CINAHL, MEDLINE in PubMed, Cochrane, OTseeker, and PsycINFO.
Study Selection and Data Collection. This systematic review followed the Cochrane Collaboration methodology and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for conducting a systematic review. Inclusion criteria were Level 1 or 2 evidence, published in English, published from January 2011 to December 2018, intervention within the occupational therapy scope of practice, and at least one IADL outcome measure.
Findings. Nineteen randomized controlled trials (including pilot and feasibility trials) and 1 preintervention–postintervention study met inclusion criteria. Results of this review show strong strength of evidence for coaching interventions in addressing physical activity (PA) routines and moderate support in addressing medication routines. Moderate strength of evidence was found with mixed results for interventions involving coaching plus prescribed PA in improving PA participation.
Conclusions and Relevance. This systematic review supports occupational therapy practitioners addressing PA and medication health management and maintenance IADLs through the use of coaching interventions when treating people with MS. Other IADLs were addressed by the articles in this review but require more evidence to make clinical recommendations.
Keywords. adult, health, multiple sclerosis, systematic reviews, occupational therapists
Cunningham, R., & McConnell, K. (2021). Occupational therapy delivered emotional regulation interventions: A case series of female patients with multiple sclerosis. International Journal of MS Care, 23(S2), 73-74. https://doi.org/10.7224/1537-2073-23.s2.1 Show abstract
Background. Emotional health disorders are common in the multiple sclerosis (MS) population and can cause significant deficits in quality of life and occupational performance. Individuals with MS experience emotional health disorders at higher rates than the general population. Lifetime prevalence rates show depression can affect up to 54% and anxiety disorders can affect up to 35.7% of people living with MS. Adjustment disorders occur in 22% of individuals within 2 months of being diagnosed with MS. Despite these statistics, emotional health disorders and related needs often go underdiagnosed and undertreated. Occupational therapy practitioners (OTPs) can address emotional regulation in clinical treatment as a component of the occupational performance area of health management and maintenance instrumental activities of daily living. This includes developing, managing, and maintaining health-promoting habits and routines to improve occupational performance, health, and quality of life. Specific interventions include education, trigger identification, technique training, self-monitoring, and symptom response planning.
Objectives. Describe the delivery of emotional regulation interventions in patients with MS and provide a descriptive case series with clinical outcomes to demonstrate how these interventions can be integrated into an occupational therapy (OT) plan of care for females with MS.
Methods. The subjects (n = 4) included in this case series participated in an average of 15 OT sessions over the course of their individual plans of care. All subjects were female, diagnosed with an emotional health disorder, and were between the ages of 30 and 53 years at time of treatment. The Canadian Occupational Performance Measure (COPM), Multiple Sclerosis Quality of Life Inventory (MSQLI), and Health Related Quality of Life Short Form-36 (SF-36) were administered at pre- and post-intervention.
Results. Overall, subjects demonstrated significant improvements throughout the course of their respective plans of care. Clinically significant improvements occurred in the COPM aggregate performance and satisfaction scores, with patients demonstrating an average 3.6-point increase on performance and 5.4-point increase on satisfaction. On average, SF-36 scores improved in 6.75 subscales including emotional well-being and vitality/energy, and MSQLI scores improved in 4.25 subscales including the Perceived Deficits Questionnaire.
Conclusions. This case series supports the delivery of emotional regulation interventions by OTPs over the course of a plan of care to address emotional health needs in females with MS. Additionally, these findings contribute to the broader evidence for the benefits of addressing emotional health needs in the MS population.
Keywords. Management of activities of daily living in MS, Psychological issues and MS, Self-care
Cunningham, R., & Uyeshiro Simon, A. (2021). Physical activity interventions for health management and maintenance for adults with multiple sclerosis [Critically Appraised Topic]. American Occupational Therapy Association. Full text
Uyeshiro Simon, A., & Cunningham, R. (2021). Interventions to improve IADL performance among adults with multiple sclerosis [Critically Appraised Topic]. American Occupational Therapy Association. Full text
Miller, V., & Cunningham, R. (2020). Lifestyle Redesign for multiple sclerosis: A case series of female Hispanic patients. International Journal of MS Care, 22(S2), 76. https://doi.org/10.7224/1537-2073-22.s2.1 Show abstract
Background. Research indicates that the incidence rate and clinical presentation of multiple sclerosis (MS) varies between patients of different ethnic backgrounds. On average, the incidence rate of Hispanic patients with MS tends to be lower than that of non-Hispanic whites, while the average age of first reported MS symptom is earlier in the Hispanic population. Hispanic patients have higher incidence of cervical spinal lesions, mobility impairments, and optic neuritis at first MS-related event. Patients with MS of Hispanic descent may be at a higher risk of disability earlier in the disease process. Due to the identified clinical presentation and disability risks, it is critical to provide rehabilitation services that will support symptom and disease management. Evidence in the MS literature supports behavior and lifestyle interventions as critical components for symptom and disease management, as well as improved quality of life. Lifestyle Redesign is an occupational therapy (OT) approach that focuses on helping patients acquire health-promoting habits and routines to improve overall function, health, and quality of life, as well as to improve self-management of chronic conditions. This methodology involves education, occupational self-analysis, personal exploration, and goal setting interventions, to facilitate reflection and increase motivation for and the enactment of health-promoting behavior changes.
Objectives. Describe the delivery of Lifestyle Redesign to address chronic disease and symptom management in patients with MS within an OT plan of care and provide a descriptive case series with clinical outcomes to demonstrate how this intervention can be applied clinically with Hispanic females with MS.
Methods. The subjects included in this case series participated in an average of 11 OT sessions. All subjects are female, of Hispanic descent, and between the ages of 20 and 45. The Canadian Occupational Performance Measure (COPM), Multiple Sclerosis Quality of Life Inventory (MSQLI), and Health Related Quality of Life Short Form-36 (SF-36) were used at pre- and postintervention.
Results. Clinically significant improvements occurred in the COPM overall performance and satisfaction scores, with patients demonstrating an average 5.3-point increase on performance and an average 7.2-point increase on satisfaction. On average, SF-36 scores improved in 7 subscales including emotional well-being, social functioning, and bodily pain, and MSQLI scores improved in 3 subscales including the MFIS.
Conclusions. This case series supports the use of Lifestyle Redesign to address symptom and chronic disease management in Hispanic females with MS because of the demonstrated benefits in the areas of functional performance and symptom presentation. Additionally, this case series contributes to the broader evidence for the feasibility of Lifestyle Redesign services for neurologic populations.
Keywords. Comprehensive care and MS, Lifestyle interventions, Management of activities of daily living in MS
Cunningham, R., & Valasek, S. (2019). Occupational therapy interventions for urinary dysfunction in primary care: A case series. American Journal of Occupational Therapy, 73(5), 7305185040p1-7305185040p8. https://doi.org/10.5014/ajot.2019.038356 Show abstract
Urinary dysfunction is commonly reported in primary care contexts. A shortage of primary care providers is affecting access to relevant services. Occupational therapy practitioners work in primary care settings and typically address urinary dysfunction in an outpatient context. Evidence regarding the delivery of occupational therapy interventions for urinary dysfunction in primary care has been limited. In this study, 3 women received 9–14 occupational therapy sessions in a primary care setting to address urinary symptoms. Plan-of-care duration, assessments, and urinary dysfunction interventions were individualized to accommodate personal and environmental factors. Across all case-series participants, Canadian Occupational Performance Measure scores demonstrated clinically significant improvement. Mixed results were found for SF–36 health-related quality-of-life subscale scores. Assessment scores specific to urinary dysfunction decreased, indicating reduced symptom severity and functional impact. This article provides preliminary evidence regarding the feasibility of occupational therapy interventions addressing urinary dysfunction in primary care settings.
Cunningham, R. (2019). Occupational therapy delivery of cognitive behavioral therapy for insomnia (CBT-I) in a patient with multiple sclerosis: A case study. International Journal of MS Care, 21(S1), 94. https://doi.org/10.7224/1537-2073-21.s1.1 Show abstract
Background. Recent data suggest that over 50% of individuals living with multiple sclerosis (MS) report significant sleep disruption and difficulty maintaining a consistent sleep schedule. Additionally, approximately 40% of those living with MS report insomnia as their primary sleep disturbance. Sleep disruption can negatively impact energy, cognitive function, quality of life, and functional participation in daily activities. Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent intervention that is considered to be the frontline treatment for addressing chronic insomnia, and has been used in a variety of populations to improve sleep quality, efficiency, and duration. Occupational therapists address sleep participation and sleep preparation in clinical treatment as a component of the occupational performance area of “rest and sleep.” This includes establishing sleep patterns, preparing the physical environment, taking care of needs to ensure sleep onset and maintenance, and routine engagement that prepares a person for rest.
Objectives. Describe the delivery of CBT-I to address insomnia within the course of an occupational therapy (OT) plan of care, and provide a descriptive case study with clinical outcomes to demonstrate how this intervention can be applied clinically with the MS population.
Methods. The patient participated in 10 OT sessions with sleep addressed in the course of a typical plan of care through the use of CBT-I delivery. The Insomnia Severity Index (ISI), Canadian Occupational Performance Measure (COPM), Multiple Sclerosis Quality of Life Inventory (MSQLI), and Health-Related Quality of Life Short Form-36 (SF-36) were utilized at pre- and post-intervention. Additionally, total sleep time, total time in bed, sleep efficiency, and other related data were collected through the use of the modified consensus sleep diary.
Results. Data showed increased total sleep time and sleep efficiency, with reduced average number of awakenings per night. Clinically significant improvements occurred in the COPM overall performance and satisfaction scores, as well as sleep specific item performance and satisfaction scores. ISI score decreased indicating a reduced severity of insomnia symptoms. Finally, SF-36 scores improved in 8 subscores including emotional well-being and energy, and MSQLI scores improved in 3 subscales, including the Perceived Deficits Questionnaire (PDQ).
Conclusions. This case study supports the use of CBT-I to address insomnia in the MS population due to the demonstrated primary benefits for sleep quality and duration, as well as secondary benefits achieved in areas of functional performance and symptom presentation. Additionally, this case study contributes to the growing evidence for the feasibility of CBT-I delivery by an OT practitioner and incorporation into a typical OT plan of care.
Keywords. Management of activities of daily living in MS
Reeves, L., & Cunningham, R. (2019, April). Epilepsy care: An outpatient, lifestyle management approach. Poster presentation at the AOTA Annual Conference, New Orleans, LA.
Cunningham, R., & Uyeshiro Simon, A. (2018). Occupational therapy’s role in bowel and bladder symptom management in Multiple Sclerosis (Abstract). International Journal of Multiple Sclerosis Care, 20(Suppl. 1), 85. https://doi.org/10.7224/1537-2073-20.s1.1 Show abstract
Background. Bladder symptoms are reported by 80% of individuals with multiple sclerosis (MS), and approximately 50% of the MS population report bowel symptoms. Evidence demonstrates a significant correlation between urinary symptoms and longer disease duration, increased physical disability, and reduced quality of life. Bowel dysfunction can lead to decreased quality of life and social isolation. Evidence has shown that early recognition and treatment of bowel and bladder dysfunction may reduce the severity of symptom progression and improve health-related quality of life. Occupational therapists (OTs) address toileting and toileting hygiene in clinical treatment as a component of a person’s activities of daily living (ADLs). This includes positioning, care for continence needs, completion of intentional control of urination and bowel movements, and use of equipment/agents for bladder control. OT interventions that can be used to address this ADL include adaptive equipment training, pelvic floor training, relaxation techniques, bladder retraining, habit and routine management, and positioning.
Objectives. Describe OT intervention strategies for management of bowel and bladder dysfunction in patients with MS and provide a descriptive case study with clinical outcomes to demonstrate how some of these strategies can be applied clinically.
Methods. The case study subject has participated in 14 OT sessions with expected discharge in the next month. Patient’s bladder symptom management is one priority of the plan of care. The Canadian Occupational Performance Measure (COPM), Multiple Sclerosis Quality of Life Inventory (MSQLI), and RAND Short Form-36 (RAND SF-36) are the outcome measures used at pre- and post-intervention.
Results. Pre-intervention outcome data include the following: COPM overall performance score 5.4 and overall satisfaction score 4.4; RAND SF-36 sub-scores physical function 5, energy/fatigue 10, emotional well-being 76, social function 38, general health 20; and MSQLI scales MFIS 17, PDQ 5, BLCS 5, and BWCS 0. Postintervention outcome measures will be collected upon reassessment and discharge from OT services and reported at the conference.
Conclusions. This case study highlights the strategies OTs can use to address management of bladder and bowel dysfunction for individuals with MS, and it demonstrates the benefits of OT interventions in improving engagement in toileting and toileting hygiene ADL routines.
Keywords. Comprehensive care and MS, Management of activities of daily living in MS
Uyeshiro Simon, A., & Cunningham, R. (2017). Lifestyle Redesign for multiple sclerosis: A community-based occupational therapy program. International Journal of MS Care, 19(S1), 69-70. https://doi.org/10.7224/1537-2073-19.s1.1 Show abstract
Background. Multiple sclerosis (MS) can affect an individual’s ability to perform daily activities due to functional difficulties. Occupational therapy (OT) helps people to participate in these activities of daily life to improve health and independence across the lifespan. Lifestyle Redesign® (LRD) is the process of acquiring health-promoting habits and routines to improve overall function, health, and quality of life. The LRD technique has been shown to slow declines associated with typical aging, and improve overall health, functioning, and life satisfaction.
Objectives. To apply the LRD technique to a community-based population with MS for quality improvement purposes.
Methods. This community-based program is a 12-week course in which OT students deliver group and individual LRD interventions once per week for participants living with MS. The National Multiple Sclerosis Society recruits the participants, who also receive physical therapy (PT) for the duration of the program. The LRD technique uses didactic presentation, occupational self-analysis, and hands-on activity-based learning to address topics such as fatigue management, bowel and bladder function, stress management, adaptive equipment, self-advocacy, and sexual function. Outcome measures utilized pre- and post-program were the Canadian Occupational Performance Measure (COPM) and Modified Fatigue Impact Scale (MFIS). Paired-samples t tests were used to determine significant changes pre- and post-program.
Results. COPM Performance score mean increased by 1.77 points (P < .0001, df = 94), and COPM Satisfaction score increased by 2.71 points (P < .0001, df = 94). On average, participants improved their perceived participation and overall satisfaction in self-identified areas of function and lifestyle difficulty. MFIS Physical Subscale mean decreased by 4.07 points (P < .0001, df = 41), Cognitive Subscale mean decreased by 4.26 points (P = .0002, df = 41), and Psychosocial Subscale mean decreased by 0.94 points (P = .0057, df = 41). Total MFIS Score revealed a mean decrease of 9.24 points (P < .0001, df = 41). On average, participants felt that the impact of fatigue on various areas of functioning was lessened by the end of the program.
Conclusions. This quality improvement study suggests that LRD can be an effective OT intervention for people living with MS to improve their function, health, and quality of life. More controlled research is needed to further investigate effects of LRD without confounding factors (eg, PT) in MS care.
Keywords. Comprehensive care and MS, Lifestyle and behavioral modification in MS, Management of activities of daily living in MS
Outstanding Reviewer Award | 2022
American Journal of Occupational Therapy
Certificate of Appreciation for Valuable Contribution | 2016-2020
Occupational Therapy Association of California
Six Trojans featured in May issue of OT Practice >
Five USC Chan faculty members and one alumna made the pages of the May 2020 issue of OT Practice magazine.
May 22, 2020
Latest issue of AJOT features 23 USC-affiliated authors >
Katie Jordan is guest editor of the journal’s special issue on primary care
September 30, 2019
AOTA’s Everyday Evidence podcast: Best practices for adults with Multiple Sclerosis featuring Dr. Rebecca Cunningham and Dr. Ashley Uyeshiro >
Dr. Cunningham and Dr. Uyeshiro discuss their work in the University of Southern California Multiple Sclerosis clinic and their contributions to an AOTA systematic review — "Interventions within the scope of occupational therapy practice affecting instrumental activities of daily living (IADLS) for adults with Multiple Sclerosis." They share personal knowledge gained from lived experiences working with clients who have MS, students learning to think like OT practitioners, and with the Lifestyle Redesign approach to treatment.
American Occupational Therapy Association | October 6, 2021
Thought Control: Keeping Your Brain Sharp With RRMS >
Asst. Clinical Professor Rebecca Cunningham gives tips for maintaining occupation-based cognitive function with relapsing-remitting multiple sclerosis.
Sarah Ellis, in healthcentral.com | February 26, 2021