 |
[2008 updates are highlighted in red]
This population of patients has the greater needs in the management of its increasing disability. These include:
• Rehabilitation and symptomatic management
• Easy access to responsive and coordinated services
• Appropriate level of expertise
• Good communication
• Self-management
A comprehensive rehabilitation programme may be particularly appropriate although its evaluation may prove challenging. The difficulties of evaluating any intervention within the context of a randomized, double-blind, placebo-controlled trial in a variable and unpredictable condition such as MS were outlined in Chapter 1. Evaluating as broad an area as neurorehabilitation, which at the same time has to meet the specific needs of an individual patient, poses additional problems in trial design. Chief among these are a lack of detailed description (e.g., number of disciplines involved, techniques employed, etc.) and inadequate standardization of input, including its duration and location (inpatient, outpatient, or community-based). There also is reluctance among therapists to use a control group, and limited resources often prohibit the use of independent assessors, which is particularly important when blinding is so difficult and perhaps even impossible. Finally, there is no consensus as to the most appropriate outcome measures, and until recently there has been inconsistent use of limited and often inappropriate tools.
Despite these obstacles, it is possible to attempt some degree of evaluation, as has been demonstrated by a number of recent studies, although many more are required. The two key questions that need to be answered are:
1. Is comprehensive rehabilitation effective in improving ability, participation, and quality of life?
2. If so, do these benefits carry over in the medium to long term?
The majority of studies have evaluated inpatient rehabilitation, which may be more accessible for study design. Of the nine studies of in-patient rehabilitation listed in Table 4-2, three are of single group design, although all suggest potential benefit from rehabilitation in the area of disability.
| Table 4-2: Summary of Recent Outcome Studies of Comprehensive Rehabilitation in People with MS | | Study | Study Design | Sample | Main Outcomes/Instruments | Time of Assessments | Results | | Inpatient Rehabilitation | | Franca- bandera et al. | Prospective, stratified, randomized study | 84 | ISS. Need for home assistance (hours) | Admission and 3-month intervals for 2 years | Preliminary results suggest marginal benefit in inpatient group | | Kidd et al. | Prospective, single-group, pre- and post-study design | 79 | DSS, Barthel Index, ESS | Admission and discharge | Significant improvement in disability and handicap | | Freeman et al. | Prospective, single group, longitudinal study design | 50 (prog MS) | EDss and FS, FIM, LHS, SF-36, GHQ-28 | Admission and discharge and at 3-month intervals for 1 year | Benefits in disability, handicap, Qol and emotional well-being persist for 6-9 months | | Solari et al. | Randomized single group study comparing inpatient and home exercise programme | 50 (ambu- latory) | EDSS, FIM, SF-36 | Baseline 3, 9 and 15 weeks | Benefits in disability and some aspects of Qol | | Aisen et al. | Retrospective, single group, pre- and post-study design | 37 | EDSS and FS, FIM | Admission, discharge and telephone follow-up (between 6 and 36 months post discharge) | Significant improvement in both FIM and EDSS | | Kidd, Thompson | Prospective, single group, pre- and post-study design | 47 | ED SS, FIM, ESS | Admission, discharge and 3-months follow-up | Gains in disability maintained at 3 month;
Handicap improved over study period | | Freeman et al. | Stratified randomized, wait list controlled study design | 60 (prog. MS) | EDSS and FS, FIM, LHS | Baseline 6 weeks | Significant benefit in disability and handicap | | Romberg et al. | Randomized controlled study | 95 | Timed walk test upper and lower limb strength balance | Baseline and 6 months | Improvement in TWT and upper limb endurance | | Storr et al. | Randomized, parallel group, blinded trial | 90 | MSIS, EDSS, GNDS, 9HP, TWT | Baseline and 10 weeks | no benefit | | Outpatient Rehabilitation | | Di Fabrio et al. | Non-equivalent pre-test, pro-test control group design | 45 (prog. MS) | MS-related symptom.
RIC-FAS Fatigue frequency | At entry and at 1 year | 33 patients completed 1 year. Significant benefit seen in MS-related symptoms inc fatigue | | Patti et al. | Randomized, controlled trial | 111 | EDSS and FS, FIM, SF-36 | Baseline and six weeks | Significant improvement in FIM | | BUSTOP: Burke Stroke Time-oriented Profile; CRDS: Computerized Re- habilitation and Data System; DSS: Disability Status Scale; EDSS: Expanded Disability Status Scale; ESS: Environmental Status Scale; FIM: Functional Independence Measure; LORS-II: Revised Level of Rehabilitation Scale; FS: Functional Systems; ISS: Incapacity Status Scale; LHS: London Handicap Scale; SF-36: Short Form 36 Health Survey Questionnaire; GHQ-28: 28-item General Health Questionnaire; RIC-FAS: Rehabilitation Institute of Chicago Functional Assessment Scale. |
The study by Freeman and co-workers was a randomized, wait-list controlled study of 66 patients with progressive MS. Patients were stratified on entry according to EDSS score, and the treatment group received a short period of inpatient rehabilitation (mean, 20 days). Measures of disability, the Functional Independence Measure (FIM), and handicap, the London Handicap Scale (LHS), were applied on entry into the study and 6 weeks later. The two groups were well matched in relation to age, sex, disease pattern, and duration, and the treated group showed a significant benefit in both disability (p<0.001) and handicap (p<0.01) when compared with the control group. No change in the EDSS score was seen in either group.
A randomized, single-blind trial compared a 3-week inpatient rehabilitation program with a home exercise program in 50 less disabled patients who were still ambulatory. Patients were evaluated with the EDSS, FIM, and SF-36, a quality-oflife measure, at baseline, 3, 6, 9, and 15 weeks. Significant benefit in disability and some aspects of quality of life (mental not physical) was seen at the end of the 3-week period in the rehabilitation group compared with those doing a home exercise program. This beneficial difference between groups was seen again at 9 weeks but had disappeared by 15 weeks.
A more recent study assessed the role of strength and aerobic training, initially as an in-patient for three weeks but followed by 23 weeks at home in patients with MS of mild to moderate severity. Benefits in mobility and upper limb endurance were seen in the intervention group when compared to controls. In contrast a study of in-patient rehabilitation showed no benefit in patients whose MS was stable.
Few researchers have attempted to evaluate outpatient based rehabilitation in MS. One study randomly assigned 46 patients with progressive MS to an active treatment group (20 patients receiving 5 hours of outpatient therapy a week for 1 year) and to a wait-list control group. The range of outcomes used included an MS-related symptoms checklist composite score, a measure of fatigue frequency, and items from the Rehabilitation Institute of Chicago’s Functional Assessment Scale. A significant reduction in the frequency of MS symptoms and fatigue was seen. A more recent randomized controlled trial of outpatient rehabilitation involved 111 patients with progressive MS. Those in the treatment arm underwent a 6-week period of treatment. The primary outcome measure was the FIM and moderately significant benefits (effect size greater than 0.4) were seen in the total score and in the sphincter, self-care, transfers, and locomotion sub-scores.
Table 4-3
Systematic reviews in MS
| Systematic reviews in MS | | Topic of review | Year | Authors | Published in | |
| Occupational therapy for multiple sclerosis | 2003 | Steultjens EM, Dekker J, Bouter LM et al | Cochrane Database Syst Reviews | |
| Exercise therapy | 2006 | Rietberg MB, Brooks D, Uitdehaag BMJ et al | Cochrane Library | |
| Multidisciplinary rehabilitation | 2007 | Khan F, Turner-Stokes L, Ng L et al | Cochrane Library | |
| Treatment for ataxia | 2007 | Mills RJ, Yap L, Young CA | Cochrane Database Syst Reviews | |
| Psychological interventions | 2006 | Thomas PW, Thomas S, Hillier C et al | Cochrane Database Syst Reviews | |
| Exercise training on quality of life | 2008 | Motl RW, Gosney JL | Multiple Sclerosis | |
| Physical exercise | 2008 | Dalgas U, Stenager E, Ingemann-Hansen T | Multiple Sclerosis | |
|
