A randomised controlled trial comparing rehabilitation against standard therapy in multiple sclerosis patients receiving intravenous steroid treatment.
Craig J, Young CA, Ennis M, Baker G and Boggild M;
Commented by , 23 Oct 2003
Background
Studies of rehabilitation in MS are limited, but have mostly shown an effect on functional and self reported measurements. The effect on disability and impairment is primarily observed in relapsing MS. Steroid therapy is considered to be the most important relapse treatment, accelerating recovery rapidly.
The effect of intravenous methylprednisolone (IVMP) on recovery after acute relapse, has been described by Bethoux et al.(Mult Scler;7:137-42.2001), and showed immediate improvement of impairment and disability, but prolonged improvement of self reported health status. The current study seeks to enlighten the effect of IVMP and multidisciplinary team care (MDT) in combination, following acute exacerbation in MS.
Aim
To evaluate the benefit of IVMP and MDT compared to IVMP alone.
Methods
MS subjects with acute relapse requiring admission were treated with a three day course of IVMP 1 g/day. The patients were randomized to general neurological physiotherapy (either as an in-or out patient) within available resources or received a planned, multidisciplinary team assessment. In the latter group, goals were set for treatment effect and advice was given for self management after discharge.
The primary outcome measures were Guy’s Neurological Disability Scale (GNDS) and the Amended Motor Club Assessment (AMCA). The secondary measures were the Barthel Index (BI), the Human Activity Profile (HAP), and the Short Form 36 Item Health Survey (SF 36). The statistics consisted of parametric (ANOVA) and non-parametric (Mann-Whitney) tests, according to the distribution of data.
Results
40 subjects completed the study. Baseline analysis showed no difference in level of disability (mean EDSS at time of relapse were 5.4 in the treatment group, 5.1 in the controls). The mean change difference of GNDS and AMCA between groups was statistically significant (p<0.05) in favor of planned MDT care. This was also the case for BI, HAP and four domains of the SF-36 (Physical Function, Social Function, Role Emotional, and Mental Health).
Discussion
The study is the first to show that planned and focused MDT following MS relapse treatment is beneficial. The study thus provides a very good argument, for implementing a more substantial and formalized treatment and rehabilitation program, following acute relapses.
Other results also call for attention in this context, since CNS remyelination, as well as neural reorganization and adaptation, has been shown to take place in the initial phase after relapse. It is therefore important that that the efficacy of rehabilitation is described and optimized, especially since improved medical treatment provide a new basis for regeneration of neural function in MS.
One of the drawbacks of the study is the relatively short observation period of three months. I would have been interesting to see the effect of MDT on impairment and quality of life after a longer time interval.
Finally, it should be mentioned that the most important impairment score (AMCA) was assessed by a non-blinded rater, which could have biased the results. It would therefore be interesting to see if future studies can reproduce the results.