Evidence into Practice Multiple Sclerosis Rehabilitation Program RPC RMH

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Evidence into Practice Multiple Sclerosis
Rehabilitation Program RPC RMH

• Fary Khan
• Department of Rehabilitation
• Medicine, University of Melbourne
• and the Royal Melbourne Hospital

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Royal Melbourne Hospital Royal Park Campus
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RPC - RMH Rehabilitation Department
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Neurorehabilitation activity at RPC

• 20/35 IP beds
• Ambulatory Services
• Neurorehabilitation streams
• Stroke
• Neurology (MS, Spina Bifida, Cerebral palsy,
  CIPD, GBS, MND, PPS, SCI, Epilepsy, Parkinsons)
• Neurosurgical (Tumours, all surgery)
• Trauma (TBI)

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MS Rehabilitation Stream

• IP / OP/ Home based services
• Links with
• Pain Service
• Continence Service
• Spasticity (Botulinum Toxin) Clinic
• Consumer Organizations Carer Groups
• DHS

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MS Overview

• 2.5 million people worldwide, 7000 MS Registry
  (MSSA 2007)
• 3rd most common cause of disability in young
  adults (Dombovy 1991)
• Lifelong, fluctuating disability, uncertain
  course -usually progressive
• More frequent need for evaluation c/w other
  neurological conditions (Brown 2005)
• Costly 2.5 million / year (Whetton 1998)

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Variable prognosis

• 50 gait aid within 15 yrs of onset (Weinshenker
  1989)
• 70-80 unemployed after 5 yrs of diagnosis
  (Kornblith 1986)
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• Normal life expectancy (Finlayson 2004)
• management of many disabilities
• age related changes, overuse syndromes

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Complexity in MS

• Unpredictable course
• Heterogeneous patient population
• Many combinations of impairments, activity
  limitations participation
• Currently no tools fully capture these complex
  constructs

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Complexity in MS Rehabilitation

• Rehabilitation programs are
• Tailored
• Realistic achievable
• Goal focused
• Time based
• Active patient participation
• Intensity, setting, type and timing of
  rehabilitation treatment

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Models for Implementation

• NICE- Clinical Guidelines for MS (UK NICE 2004)
• NSF- identified MS as one of the Long term
  neurological conditions (UK NSF 2005)
• NSF focuses on ways to improve health and social
  care services for independent living for persons
  with long term neurological conditions
• Evidence Base for MD Rehabilitation

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NICE GuidelinesKey areas of implementation

• Mx MS in primary and secondary care
• PwMS referred to specialised services
• Rapid diagnosis (12 weeks)
• Seamless, responsive service
• Sensitive but thorough problem assessment
• Guidance for referral post discharge

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NSF Broad Characterizations of Conditions

• Sudden onset - ABI, SCI, Stroke
• Intermittent and unpredictable - epilepsy, RRMS,
  types of headaches
• Progressive conditions - MND, SPMS, Parkinsons
• Stable neurological conditions - CP, PPS
• Range of problems, different time courses and
  persons with different experiences
• Role of rehabilitation to enhance recovery is
  well established in SCI, Stroke but less so in
  progressive disease such as MS

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Care Pathways addressed by the Quality
Requirements in the NSF for long term Conditions
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Evidence for MD rehabilitation in MS?

• Multidisciplinary Rehabilitation for adults with
  Multiple Sclerosis (Review)
• Khan F, Turner Stokes L, Ng L, Kilpatrick T
• The Cochrane Database of Systematic Reviews 2007
• Issue 2. Art No CD006036.DOI 10.1002/14651858

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Objective

• To assess the effectiveness of organized MDR in
  adults with MS
• MDR definition
• IP, Domiciliary (OP, home, community based
  program)
• delivered by gt 2 disciplines in conjunction with
  physician consultation
• targeted towards improvements at the level of
  activity and /or participation

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Methods

• Cochrane MS Group Methods Search Strategy
• identified all RCT 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
• 3 reviewers selected trials and rated
  methodological quality
• Methodological quality criteria (n 17) internal
  validity, descriptive and statistical criteria-
  van Tulder (1997, 2003)

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Methods

• Quantitative analysis was not possible - use of
  diverse outcomes clinical heterogeneity
• Qualitative synthesis of 'best evidence' -
  presented based on levels of evidence - van
  Tulder (2003)
• Subgroup analysis - type, setting intensity of
  rehabilitation duration of patient follow up

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Main results

• 8 trials selected (7 RCTs 1 CCT)
• 747 pwMS ( 73 caregivers) from UK, US Italy
• Patients
• Definite MS
• All stages of disease
• Between 18 - 64 years of age (mean 38 - 50 years)
  
• Mostly women (range 50 -100)
• Range of disability (EDSS score range 3.6 - 9)

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Main results

• 7 RCTs scored well and one CCT scored poorly on
  the methodological quality assessment
• Strong evidence - IP LL mobility, transfers
  participation
• Moderate evidence - OP mobility transfers,
  self-care, sphincter control, QoL, SE, HP
  behaviours employment 
• Moderate evidence - RITH QoL (some domains)

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Main results

• Some studies reported potential for cost-savings
  - no convincing evidence regarding long term cost
  - effectiveness
• Not possible to suggest best 'dose' of therapy or
  supremacy of one therapy over another

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Conclusion

• MDR programs 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

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Methodological Limitations

• Lack of description standardization of input
• Variation in location duration of
  rehabilitation input
• Reluctance to use a control group
• Absence of blinding
• Lack of independent assessors
• Limited, inappropriate outcome measures
• (Whyte 2002, Thompson 2000)

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Future recommendations

• High quality RCTs and other designs
• Effectiveness of specific rehabilitation
  interventions Black Box
• Components, Intensity, Settings cost
  effectiveness
• Development of appropriate, reliable and valid
  outcome measures which reflect domains of the ICF
  endorsed by WHO
• Consensus on a Core set of measurement of
  outcomes in MS trials

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RPC MS Rehabilitation Program

• Use of ICF to describe patient reported
  disability in Multiple sclerosis and
  identification of relevant environmental factors
  Khan F, Pallant J. J Rehabil Med 2007 3963-70
• Use of the International Classification of
  Functioning, Disability and Health (ICF) to
  identify preliminary comprehensive and brief core
  sets for Multiple Sclerosis. Khan F, Pallant J.
  Disability and Rehabilitation 2007 Feb 15 29
  (3) 205-13
• Use of Goal Attainment Scaling (GAS) in
  rehabilitation for persons with Multiple
  Sclerosis F Khan, J Pallant, L T- Stokes.
  Archives of Physical Medicine Rehabilitation
  accepted for publication September 2007
• Rehabilitation in Multiple Sclerosis Functional
  Outcomes in an Australian Community Cohort. A
  Randomised controlled Trial F Khan, J Pallant, T
  Kilpatrick. Submitted for publication September -
  Journal of Neurology, Neurosurgery Psychiatry

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Questions?