Multidisciplinary rehabilitation as supportive treatment for adults with multiple sclerosis

Multiple sclerosis is a chronic neurological condition, which can cause multiple disabilities and limit participation in young adults. This review looked for evidence of MD rehabilitation in adults with multiple sclerosis. The authors concluded there was strong evidence that inpatient or outpatient rehabilitation can lead to improvement in activity (disability) and in overall ability to participate in society, even though there is no reduction in actual impairment. There was limited evidence for short-term improvements in symptoms and disability, and in participation and quality of life with the high intensity outpatient and home-based rehabilitation programmes. For low intensity programmes conducted over a longer period there were longer term gains in quality of life; and for benefits to carers in terms of general health and engagement in social activities. The evidence available for other aspects of MD rehabilitation, including outpatient and home based therapy is not yet sufficient to allow many conclusions to be drawn.

Authors' conclusions: 

MD rehabilitation programmes do not change the level of impairment, but can improve the experience of people with MS in terms of activity and participation. Regular evaluation and assessment of these persons for rehabilitation is recommended. Further research into appropriate outcome measures, optimal intensity, frequency, cost and effectiveness of rehabilitation therapy over a longer time period is needed. Future research in rehabilitation should focus on improving methodological and scientific rigour of clinical trials.

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Background: 

Multidisciplinary (MD) rehabilitation is an important component of symptomatic and supportive treatment for Multiple Sclerosis (MS), but evidence base for its effectiveness is yet to be established.

Objectives: 

To assess the effectiveness of organized MD rehabilitation in adults with MS. To explore rehabilitation approaches that are effective in different settings and the outcomes that are affected.

Search strategy: 

We searched the Cochrane Multiple Sclerosis Group's Trials Register (25 February 2011), PeDRO (1990 - 2011), the Cochrane Rehabilitation and Related Therapies Field trials Register, the National Health Service National Research Register (NRR) and relevant journals were handsearched. No language restrictions were applied.

Selection criteria: 

Randomized controlled trials (RCT) and controlled clinical trials (CCT) that compared MD rehabilitation with routinely available local services or lower levels of intervention; or trials comparing interventions in different settings or at different levels of intensity.

Data collection and analysis: 

Three reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis based on methodological quality was performed. Trials were grouped in terms of setting and type of rehabilitation and duration of patient follow up.

Main results: 

Ten trials (9 RCTs and 1 CCT) (954 participants and 73 caregivers) met the inclusion criteria. Eight RCTs scored well; while one RCT and one CCT scored poorly on the methodological quality assessment. Despite no change in the level of impairment, there was ’strong evidence’ to support inpatient MD rehabilitation in producing short-term gains at the levels of activity (disability) and participation in patients with MS. There is ‘moderate evidence’ to support inpatient or outpatient rehabilitation programmes (compared with control wait-list groups) in improving disability; and bladder related activity and participation outcomes up to 12 months following MD rehabilitation intervention. For outpatient and home-based rehabilitation programmes there was 'limited evidence' for short-term improvements in symptoms and disability with high intensity programmes, which translated into improvement in participation and quality of life. For low intensity programmes conducted over a longer period there was 'strong evidence' for longer-term gains in quality of life; and also 'limited evidence' for benefits to carers. Although some studies reported potential for cost-savings, there is no convincing evidence regarding the long-term cost-effectiveness of these programmes. It was not possible to suggest best 'dose' of therapy or supremacy of one therapy over another. This review highlights the limitations of RCTs in rehabilitation settings and need for better designed randomized and multiple centre trials.

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