LONDON — A 4-week period of inpatient multidisciplinary rehabilitation was associated with improvements in quality of life in patients with multiple sclerosis (MS) in a new Danish study.

And a separate study suggested that rehabilitation exercises in MS may be effectively delivered by telecommunications — with a physiotherapist supervising the exercises by video link.

Both studies were presented at the recent Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2016 at a session led by the Rehabilitation in Multiple Sclerosis (RIMS) organization.

Presenting the Danish study, Finn Boesen, MD, Danish MS Hospitals, Haslev, Denmark, noted that the positive effects on quality of life of a 4-week rehab program were seen immediately at discharge and "most importantly" remained at the 6-month follow-up (5 months from discharge).

But during the discussion, members of the audience questioned whether the lack of active control in the study may have biased the results.

The telerehabilitation study was presented by Gabriel Pardo, MD, Oklahoma Medical Research Foundation Multiple Sclerosis Center of Excellence, Oklahoma City.

"Telerehabilitation is a convenient and practical method to perform physical therapy in MS individuals and has comparable efficacy to conventional in-person physical therapy as measured by objective outcomes of gait and balance," Dr Pardo concluded.

"Patient-reported outcomes were also favorable," he added. "Telerehabilitation should be researched further and used more extensively as a mean to improve function and quality of life in MS."

Inpatient Rehabilitation

Introducing the Danish study, Dr Boesen explained that current evidence is insufficient to support the effectiveness of inpatient rehabilitation for patients with MS.

His group therefore conducted the current study, in which 427 patients (aged 18 to 65 years; Expanded Disability Status Scale [EDSS] score, 7.5 or less) were randomly assigned (1:1) to immediate inpatient multidisciplinary rehabilitation comprising 4 weeks (20 days) of continuous hospitalization or to a control group (a 6-month waiting list).

Interventions included individual and group-based occupational therapy, individual and group-based physiotherapy, therapeutic horseback riding, group-based interdisciplinary instructions/classes, nursing, sessions with psychologists, talks with a caregiver, and self-directed exercise.

Results showed that the intervention group gained from the rehabilitation and experienced significant improvements in quality of life, as measured by the Multiple Sclerosis Impact Scale version 2 (MSIS-29) psychological dimension (P = .0258) and 15D (P = .0061) at 6-month follow-up compared with the control group.

At discharge, the scores on Functional Assessment of Multiple Sclerosis (FAMS), MSIS-29 Physical, MSIS-29 Psychological, and EQ-VAS were significantly better than at baseline (all P < .0001).

A post hoc analysis of change scores revealed that health-related quality of life was unchanged or improved at 6 months in a significantly greater proportion of the intervention group than in the control group for FAMS (P = .0487) and MSIS-29 Psychological (P = .0121). The control group deteriorated during the study period and scored significantly worse on FAMS at 6-month follow-up (P = .0004).

Dr Boesen concluded that "this pragmatic trial reflects the complexity and diversity of actual clinical practice and has relevance to clinical practitioners and management. Further studies are needed to confirm these findings."

Commenting on the study for Medscape Medical News, Nicolas LaRocca, MD, National Multiple Sclerosis Society, pointed out an obvious limitation in that it had a wait list control group.

"This means there was no active control, so any benefit seen in the intervention group could be due to the Hawthorne effect — when patients improve because of the attention they are getting, which leads to expectations of benefit. So there is a bias there. It would have been better to have an active control of some sort."

Dr LaRocca noted that the rehabilitation given was personalized to each individual patient. "This is usual practice in MS, but it does make it difficult to pin down what exact treatment is having the benefit."

"In this study the treatment improved quality of life but did not actually lead to improvement in physical function. Though some may question the value of this, I would say the goal of rehabilitation is to retain independence for as long as possible, and quality of life is an important part of this."

"Historically, quality of life has not been taken so seriously as an endpoint in MS studies, but now there has been a complete turnaround on this," he added.

Physical Therapy by Video

The telerehabilitation study involved 30 patients with MS (mean age, 54.7 years; 60% relapsing MS, 23% secondary progressive MS, 17% primary progressive MS; mean EDSS score, 4.3).

They were randomly assigned to one of the following interventions: (1) home-based exercise program performed unsupervised 5 days a week for 8 weeks; (2) home-based exercise program plus remote physical therapy supervised via audio and visual real-time telecommunication two to three times per week; or (3) home-based program plus in-person physical therapy at the medical facility two to three times per week.

Results showed that functional gait —assessment improved in all groups from baseline and did not differ between the telerehabilitation and the conventional physical therapy groups (P = .73).

Other outcomes that were similar for groups 2 and 3 were gait — timed 25-foot walk (P = .95), stride length (P = .64); balance — Berg Balance Scale (P = .98), step width (P = .91), tandem sway (P = .78), tandem width (P = .24), limits of stability (P = .90), and sensory organization test (P = .92).

"Telemedicine is potentially very important — in this study it was at least as good as rehabilitation in person," Dr LaRocca said, commenting on these study results. "I would like to see a bigger study, but this was very well designed for a pilot study. We need to establish the pros and cons of telemedicine. In this study the adherence was good in all groups — the patients actually did the exercises."

He added: "In MS, patients derive a lot of benefit from the relationship with the therapist — they are someone to talk to, a bond develops. The question is, can this be achieved with telecommunications?"

He noted that while telehealth is always targeted for people in rural areas, it can also work well in a big city, where there can also be travel issues.

"The new generation of MS patients are very amenable to electronic form of communications. It has been part of their personal culture since childhood. So telehealth has even more potential in younger patients and future patients," he concluded.

Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2016. Abstracts 116 and 120. Presented September 15, 2016.

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