Description of the condition

Multiple sclerosis (MS), an autoimmune inflammatory demyelinating disease of the central nervous system, is a major cause of chronic neurological disability in young and middle‐aged adults (aged 18 to 50 years) (Barten 2010). MS affects approximately 1.3 million people worldwide, with a median estimated incidence of 2.5 per 100,000 (with a range of 1.1 to 4) globally (WHO 2008). The global prevalence rate of MS is estimated to be 30 per 100,000 (range 5 to 80), with a female preponderance (female to male ratio of 3:1) (Trisolini 2010; WHO 2008). MS is characterised by significant variability in presentation and prognosis, and is associated with complex disabilities, including disorders of strength, sensation, co‐ordination and balance, visual, and cognitive deficits (Beer 2012; Khan 2007a; Khan 2007b). These impairments usually lead to progressive limitation of functioning in daily life, requiring long‐term multidisciplinary management. Studies have reported factors associated with worse prognosis such as: older age at onset, progressive disease course, multiple onset symptoms, pyramidal or cerebellar symptoms, and a short interval between onset and first relapse (Hammond 2000; Khan 2011).

MS has an unpredictable disease course and varied patterns of presentation, which include: 'relapsing‐remitting' MS (80% of all MS cases), characterised by exacerbations and remission, which may convert to a 'secondary‐progressive' form of MS with progressive disability acquired between attacks; 'primary‐progressive' MS (15% of all MS cases), where persons develop progressive disability from onset; and 'progressive‐relapsing' MS (5% of all MS cases), where persons begin worsening gradually and subsequently start to experience discrete attacks (Amatya 2012; Khan 2007b).

People with MS can present with various combinations of functional deficits, such as: physical disability (motor weakness, spasticity, sensory dysfunction, visual loss, ataxia), fatigue, pain, incontinence, cognitive deficits (memory, attention, executive dysfunctions), psychosocial, behavioural, and environmental problems; these have a multidimensional impact on a person's activity (function) and participation (Khan 2006; Khan 2007b). The International Classification of Functioning, Disability and Health (ICF), provides a global conceptual framework to categorise abilities and problems of persons with different health conditions, within a standard system (WHO 2001). It offers a common language for clinicians for describing functioning, disability, and health of an individual (WHO 2001). A simulated case example of the ICF model related to MS is given in Figure 1.

Figure 1

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International Classification of Functioning, Disability and Health (ICF) model with case example for multiple sclerosis.

Description of the interventions

The care needs of people with MS are complex due to cumulative effects of impairments and disabilities, the 'wear and tear' and the impact of ageing with a disability, requiring comprehensive disease management including rehabilitation. The World Health Organization (WHO) defines medical rehabilitation as "a set of measures that assist individuals who experience (or are likely to experience) disability to achieve and maintain optimal physical, sensory, intellectual, psychological and social functioning in interaction with their environment"(WHO 2011). It is a complex process of delivery of a co‐ordinated interdisciplinary care programme, comprising a series of therapies, which are often individualised and goal‐oriented to meet the specific needs of a patient (Khan 2015). The goal of rehabilitation is to improve functional independence and enhance participation, with emphasis on patient education and self‐management (Amatya 2012; Beer 2012; Khan 2007b; WHO 2011).

Although physical therapy remains a key component and the most common rehabilitation intervention in MS, it needs to be part of a comprehensive long‐term multidisciplinary rehabilitation approach to maintain functional gains and social reintegration (participation) (Khan 2007b; Khan 2010; WHO 2008). This includes a range of diverse rehabilitation intervention strategies, which may include the following.

• Unidisciplinary therapy, which may include (but is not limited to): physiotherapy or occupational therapy, strengthening exercises; endurance training, resistance training; stretching; orthotics (splints, garments); casting; hyperbaric oxygen therapy, transcutaneous electric nerve stimulation, hippotherapy, vibration therapy, vocational rehabilitation, acupuncture; psychological intervention; mental practice and educational interventions, and specific rehabilitation programmes (such as, telerehabilitation, fatigue management, upper limb rehabilitation, and spasticity management programmes).

• Multidisciplinary rehabilitation programmes involving the provision of a co‐ordinated programme by a specialised team of health professionals, delivered by two or more disciplines (nursing, physiotherapy, occupational therapy, orthotists, and others).

How the intervention might work

With advances in MS management, there is significant improvement in survival time of people with MS (median survival time from the time of diagnosis of 40 years), therefore, issues related to progressive disability (physical and cognitive), psychosocial adjustment and social reintegration need to be addressed over time (Khan 2007b). In recent years, a range of rehabilitation interventions trialled in people with MS provide increasing evidence for these interventions and improved patient outcomes (Khan 2007b; Khan 2011; Khan 2017). Specifically, physical therapeutic modalities, such as physical therapy and exercise improve muscle power/strength, exercise tolerance and mobility‐related activities (Campbell 2016; Haselkorn 2015; Rietberg 2005), and exercise‐based programmes reduce patient‐reported fatigue (Andreasen 2011; Asano 2014; Heine 2015). Some potential benefits associated with physical activities include improvements in strength and muscle activity, improvement in functional capacity (including cardiorespiratory capacity), enhanced cognition function and haemodynamic activity (Cruickshank 2015). Further, physical therapy/activity is believed to enhance neurobiological processes that could promote neuro‐protection and neuro‐plasticity and reduce long‐term disability (White 2008a; White 2008b). Likewise, it has been speculated that physical rehabilitation programmes may affect multiple sensorimotor processes (visual, vestibular, proprioception) to generate co‐ordinated movements that maintain the centre of mass within the limits of stability, thus improving balance and gait pattern (Paltamaa 2012). There is also evidence for multidisciplinary rehabilitation for longer‐term gains at the levels of activity (disability) and participation (Khan 2007b), While, other rehabilitation interventions such as occupational therapy (Steultjens 2003), transcutaneous electrical nerve stimulation (Glinsky 2007), vibration therapy (Kantele 2015), hippotherapy (Bronson 2010), and hyperbaric oxygen therapy (Bennett 2004), have been found to have no, or limited additional benefit in people with MS (Khan 2017).

Why it is important to do this overview

MS is complex and requires a comprehensive multidimensional approach to disease management, that incorporates integrated rehabilitation interventions. The body of research for the rehabilitation interventions is growing and currently there are number of Cochrane Reviews published on the efficacy and safety of various rehabilitation approaches in MS. The published reviews, however, can vary in scope and methodology, with different, and at times, diverse conclusions about the effectiveness of the intervention evaluated. Further, some review findings may overlap with each other in terms of interventions and comparisons.

The therapeutic values, including benefit and harm, associated with MS rehabilitation interventions need to be established. Further, the most efficacious approaches, timing and intensity of these interventions, resource requirements, and associated costs require investigation. To our knowledge, no studies to date have comprehensively evaluated existing Cochrane Reviews of various rehabilitation interventions in MS. A systematic evaluation of the existing evidence from published Cochrane Reviews is therefore required to provide best evidence regarding effectiveness of these interventions, to guide treating clinicians for optimal patient outcomes. This overview can serve as a 'guiding tool' for evidence‐based decisions on appropriate management approaches in MS; provide information for future programme improvement and design; inform policy/healthcare decision makers, and future research in MS.