Read Full Text: Rehabilitation for people with multiple sclerosis: an overview of Cochrane systematic reviews
Journal: Cochrane Database of Systematic Reviews
Year Published: 2017/2019
Ranked 83rd on our 2016-2021 list of the 100 Most Influential OT Research Articles
Cochrane Reviews are considered some of the best evidence available. So, when they cover a topic that’s relevant to OT, we need to pay attention!
This week’s article is a Cochrane Review of multiple sclerosis (MS) rehab. Unfortunately, you’re not going to see a rousing endorsement of OT in this review. (Hint: the word “insufficient” was used.) But, there is still so much we can learn from this paper. Not only will you find research regarding many treatments you may already be using, but you’ll also learn about some assessments that can help guide your sessions.
One big takeaway from this review is that the treatment of MS has evolved dramatically over the past few decades. And, while this might not be the shiny gold star we’d like to see for OT at this time, this review is filled with great information to help you provide the best care possible. That, alone, is worth our undivided attention 
Let’s dive in.
High-level background on MS rehab
As you probably know, multiple sclerosis (MS) is an inflammatory autoimmune disease affecting the central nervous system (CNS). It occurs when the myelin in the CNS is mistakenly attacked by the body’s own immune system.
MS has an unpredictable disease course with varied patterns or presentations, which are divided into 3 main types:
- Relapsing-remitting (80% of MS cases)
- Primary-progressive (15% of MS cases)
- Progressive-relapsing (5% of MS cases)
Per the authors, the goal of MS rehabilitation is to:
“Improve functional independence and enhance participation, with an emphasis on patient education and self-management.”
How does rehab for MS work (per our current understanding)?
While there is no cure for MS, there have been significant advancements in managing its effects. This, in turn, has led to increased survival rates. And, in recent years, a range of rehab interventions have provided increasing evidence of improved patient outcomes.
A quick overview:
Physical therapeutic modalities (such as PT and exercise) have been shown to improve:
- Muscle power and strength
- Exercise tolerance
- Mobility-related activities
- Energy levels (by reducing fatigue)
Possible benefits of physical activity also include:
- Improvement in functional capacity
- Enhanced cognitive function
- Enhanced hemodynamic activity
- Promotion of neuroprotection and neuroplasticity
- Reduction of long-term disability
Multidisciplinary rehabilitation has supporting evidence for:
- Improvement at the activity and participation level
Other rehabilitation interventions with limited (or no) benefit include:
- Occupational therapy
- Transcutaneous electrical nerve stimulation (TENS)
- Vibration therapy
- Hippotherapy
- Hyperbaric oxygen therapy
Why was this paper written?
Now, it’s important to note that the findings above came from older reviews, many of which had lower quality of evidence than the Cochrane Review does.
Given the growing body of evidence related to rehab and MS, the authors felt that it was time to write a review of Cochrane Reviews on the topic. Their hope was that the information gleaned could guide clinicians as to which therapies are most effective for treating MS.
What reviews did they find?
The authors included 15 Cochrane Reviews, which, in turn, included 164 randomized control trials (RCTs) and 10,396 people with MS. Because the authors only included Cochrane Reviews, the evidence was considered to be of high quality.
The interventions took place in:
- Ambulatory settings
- Home-based settings
- Inpatient rehab settings
How did they measure outcomes?
Here are the outcome measures they found. (And, they happen to be ones you can use in your practice!)
- 10-Meter Walk Test (10MWT)
- Barthel Index (BI)
- Caregiver Strain Scale (CSI)
- Expanded Disability Status Scale (EDSS)
- Functional Independence Measure (FIM)
- Guy’s Neurological Disability Scale (GNDS)
- London Handicap Scale (LHS)
- Modified Ashworth Scale (MAS)
- MS Quality of Life 54 (MSQOL-54)
- Timed Up and Go (TUG)
How did they grade the evidence for specific interventions?
Based on their standardized procedures, the author gave the interventions a grade based on the effect of outcomes across studies.
This grade ranged from “very high quality” to “very low quality.” None of the interventions had “very high” quality. This means that new evidence may change the status of the interventions in the future.
Moderate Quality
Physical therapy
- 54 RCTs
- Inpatient, Ambulatory, Long-Term/Community
Information provision
- 10 RCTs
- Ambulatory, Long-Term/Community
Multidisciplinary rehab
- 9 RCTs
- Inpatient and Ambulatory
Low Quality
Neuropsychological intervention
- 20 RCTs
- Inpatient, Ambulatory, Long-Term/Community
Cognitive rehabilitation
- 16 RCTs
- Inpatient, Ambulatory
Memory rehabilitation
- 15 RCTs
- Ambulatory
Spasticity management interventions
- 9 RCTs
- Inpatient, Ambulatory, Long-Term/Community
Telerehabilitation
- 9 RCTs
- Ambulatory, Long-Term/Community
Hyperbaric oxygen therapy
- 9 RCTs
- Ambulatory
Dietary Intervention (Polyunsaturated-fatty acids)
- 6 RCTs
- Ambulatory
Whole body vibration
- 4 RCTs
- Ambulatory
Vocational Rehabilitation
- 1 RCT
- Ambulatory
Very Low Quality
Occupational therapy
- 1 RCT, 2 CCTs
- Ambulatory, Long-Term/Community
Dietary intervention (Vitamin D)
- 1 RCT
- Ambulatory
So, what did occupational therapy entail in these studies?
At first glance, this looks like pretty dismal news for OT.
But, in digging deeper, you’ll see that two of the trials were based on group energy conservation courses, and one counseling intervention.
The two energy conservation trials reported a beneficial effect, but the methodology of the trials were flawed, which ultimately is what landed OT in the insufficient category.
Authors’ conclusion and recommendations
The authors conclude that MS is a complex condition, which requires tailored, coordinated, long-term, multidisciplinary care.
The evidence in this Cochrane Review supports the strategy recommending varied approaches to rehabilitation. The type and setting of interventions should be individualized based on the patients’ needs. The authors do acknowledge that current evidence should be interpreted cautiously, as available reviews did contain older studies.
In future research around MS and rehab, authors assert that patients’ and caregivers’ perspectives should be incorporated, and associated costs and/or economic benefits of interventions should also be further explored.
Takeaways for OT practitioners
(Please note: these are my personal takeaways and were not mentioned specifically in the article.)
1. Overall, MS care is improving—this is good news for our patients.
I think it’s important to pause and acknowledge just how profoundly the care for MS has improved over the past few decades. This article calls this one of the biggest success stories in medicine!
New drugs have transformed the lives of patients with MS, particularly those with relapsing-remitting MS. And, this week’s article demonstrated how the evidence behind the efficacy of rehab has improved over the past decades.
These exciting advances means that our occupational therapy care needs to keep evolving, just as the needs of our patients are evolving.
2. It was a disappointment to see occupational therapy research so underrepresented in this article.
For the many OT practitioners around the globe, who pour their hearts into caring for our MS patients, the underrepresentation of OT research in this article was disheartening. I’m not sure how we’ve arrived at a point where there are 54 PT studies to 1 OT study, but this is certainly a call to action to our profession.
I would love to hear your thoughts in the comments. I’m always interested in how practitioners on the ground can be supporting more OT-related research in this area.
2. There is still a lot in this review that can inform your practice.
To begin with, the authors’ description of rehab felt like a call to action for OTs to become more involved with this population. I mean, could this statement be any more OT??
“Improve functional independence and enhance participation, with an emphasis on patient education and self-management.”
Patient education and self-management are topics that seem to keep coming up in all of our patients with chronic conditions. (Check out our podcast on self-management for more on this.)
And, this article definitely convinced me that, like other neuro and auto-immunce conditions, we need to be talking with our patients about establishing exercise habits. There are certainly unique challenges to exercising with MS, but the potential benefits make it too important to pass up.
Finally, disease-specific assessments like the MS Quality of Life 54 (MSQOL-54) seem like a great way to open up important conversations with your patients.
I’ll be eager to hear about your go-to resources for working with this population in the comments below.
Here’s the full APA citation for this article:
Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2019 Jan 14;1(1):CD012732. doi: 10.1002/14651858.CD012732.pub2. PMID: 30637728; PMCID: PMC6353175.
, I do agree that our understanding of the microbiome is going to be a major factor in the evolution of health care over the next decades!