Multidisciplinary rehabilitation for adults with multiple sclerosis

 

Abstract

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 methods

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.

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.

 

Plain language summary

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.

 

摘要

背景

多發性硬化症成人病患的多學科復健

多學科復健是多發性硬化症症狀及支持治療中重要的一部份，但是它有效性的證據還沒有建立。

目標

評估對於多發性硬化症的成年病患，多學科復健的療效。探索在不同情況下有效的復健措施及其相關的成效。

搜尋策略

搜尋的資料來源包括:Cochrane Central Register of Controlled Trials “CENTRAL”, MEDLINE (1966 – 2005), CINAHL (1982 – 2005), PEDro (1990 – 2005), EMBASE (1988 – 2005), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register (NRR).

選擇標準

比較多學科復健和一般常規局部治療或較初級復健治療的隨機臨床試驗;或是比較不同條件設定或是不同強度下復健治療差異的試驗。

資料收集與分析

三個評論者獨立挑選試驗並評定它們方法學的品質。同時根據方法學品質作出「最佳證據」的綜合結論。再根據環境、復健方法及病人後續追蹤時間來作試驗的分類。

主要結論

共找到八個試驗，包括7個RCTs及一個1CCT。合計共有747個參與者及73個照顧者。在方法學的品質評量中，七個RCTs的分數較高，而另一個RCT的分數則很低。有強烈的證據顯示，雖然功能缺損的程度沒有改變，住院病人的多學科復健對多發性硬化症病患的活動及參與度有短期的好處。對門診病人和在家作復健的病人來說，只有「有限的證據」表示高強度的復健對症狀和活動力的改善有好處。至於較長時間的低強度復健則顯示有很強的證據可以改善長期的生活品質; 對照顧者的好處則證據有限。雖然有的研究宣稱可能幫助節省費用，我們尚找不到有足夠說服力的證據來證明這些復健活動長期合乎成本效益。我們迄今尚無法建議治療最好的復健「劑量」或是採用何種復健比另一種好。這篇評論特別強調了RCTs的在復健條件設定的限制。因此我們需要設計得更好的隨機及多中心試驗。

作者結論

多學科復健沒有辦法改變殘疾，但是可以改善MS患者活動力和參與度的生活經驗。我們建議定期評估這些病患的復健成效。我們需要繼續且更長期間來研究適當的療效測量、最佳的治療強度、頻率、及成本效益。未來復健相關的研究應該聚焦在改善臨床試驗的方法學和科學的嚴謹性。

翻譯人

本摘要由新光醫院葉旭霖翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

多發性硬化是一個慢性神經學的問題，可以造成多方面的殘疾，而且限制年經人參與生活。這篇評論是尋找多學科復健好處的證據。作者的結論是有很強的證據證明復健可以使活動力進步，能增進參與生活的能力，即使復健沒有辦法減低事實上的殘疾。對門診病人和在家作復健的病人來說，只有「有限的證據」表示高強度的復健對症狀和活動力的改善有好處。至於較長時間低強度的復健則顯示有很強的證據對長期生活品質有好處; 對照顧者的好處則只有有限的證據。至於其他關於門診病人和在家復健的病人目前還沒有足夠的證據作出結論。