Rehabilitation for persons with multiple sclerosis

Review questions

Do people with multiple sclerosis (MS), who participate in rehabilitation programmes, improve in their functional activities, disability, and quality of life compared with those who receive no rehabilitation treatment, placebo, or different types of interventions?

Background

MS is a complex condition, which requires comprehensive, long-term management. Rehabilitation programmes aim to improve function, well-being, and quality of life for people with MS. Currently, a wide variety of rehabilitation therapies are used to treat MS. Published literature, including Cochrane Reviews, that evaluates these interventions, has grown. To guide clinicians, this review assessed current Cochrane Reviews, and provides an overview of the effectiveness of rehabilitation therapies used to treat people with MS.

Study characteristics

We searched for all published Cochrane Reviews of MS clinical trials that evaluated the effectiveness of rehabilitation interventions compared with various control groups (no intervention or different type of intervention). We evaluated all relevant reviews, and summarised the findings.

Key results and quality of evidence

We included a total of 15 Cochrane Reviews, which included 168 clinical trials, and a total of 10,396 people with MS. These good-quality reviews evaluated a range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy, whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity.

The findings showed some benefits for people with MS who participated in exercise and physical activity programmes or multidisciplinary rehabilitation programmes (where the intervention is provided by a team of health professionals from different professions). They found improvements in everyday activities, function, and health-related quality of life, compared with those who were not offered rehabilitation. Evidence for other rehabilitation modalities was limited, due to lack of good-quality studies. More research is needed to determine whether various types of rehabilitation modalities are effective in reducing disability in people with MS.

Authors' conclusions: 

The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit, although the certainty of evidence varies across the different types of interventions evaluated by the reviews. Structured, multidisciplinary rehabilitation programmes and physical therapy (exercise or physical activities) can improve functional outcomes (mobility, muscle strength, aerobic capacity), and quality of life. Overall, the evidence for many rehabilitation interventions should be interpreted cautiously, as the majority of included reviews did not include data from current studies. More studies, with appropriate design, which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge.

Read the full abstract...
Background: 

Multiple sclerosis (MS) is a major cause of chronic, neurological disability, with a significant long-term disability burden, often requiring comprehensive rehabilitation.

Objectives: 

To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge.

Methods: 

We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) tool, and the quality of the evidence for reported outcomes, using the GRADE framework.

Main results: 

Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R-AMSTAR criteria.

Moderate-quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge. Low-qualitty evidence suggested that neuropsychological interventions, symptom-management programmes (spasticity), whole body vibration, and telerehabilitation improved some patient outcomes. Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies.

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