Symptomatic Therapy and Rehabilitation in Primary Progressive Multiple Sclerosis

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating disease of the central nervous system and a major cause of chronic neurological disability in young adults. Primary progressive MS (PPMS) constitutes about 10% of cases, and is characterized by a steady decline in function with no acute attacks. The rate of deterioration from disease onset is more rapid than relapsing remitting and secondary progressive MS types. Multiple system involvement at onset and rapid early progression have a worse prognosis. PPMS can cause significant disability and impact on quality of life. Recent studies are biased in favour of relapsing remitting patients as treatment is now available for them and they are more likely to be seen at MS clinics. Since prognosis for PPMS is worse than other types of MS, the focus of rehabilitation is on managing disability and enhancing participation, and application of a “neuropalliative” approach as the disease progresses. This chapter presents the symptomatic treatment and rehabilitation for persons with MS, including PPMS. A multidisciplinary approach optimizes the intermediate and long-term medical, psychological and social outcomes in this population. Restoration and maintenance of functional independence and societal reintegration, and issues relating to quality of life are addressed in rehabilitation processes

Medical rehabilitation in natural disasters

© 2017 Dr. Bhasker AmatyaThe number of severe natural disasters (such as earthquakes, storms, draught, floods etc.) has escalated in recent years. Natural disasters often occur unexpectedly, precipitously and with great magnitude of destruction, resulting in significant loss of life and long-term disability from severe injuries including spinal cord injury, traumatic brain injury, limb amputation, fracture, peripheral nerve injury, crush injury and psychological impairment. In the last two decades, advances in disaster response/rescue and field management, have improved the survival rates of disaster victims significantly worldwide. Current data shows a significant increase in the number of injuries sustained relative to mortality, indicating medical rehabilitation is integral to comprehensive disaster management. Empirical evidence on medical rehabilitation following natural disasters is increasing and various studies have reported effectiveness of rehabilitation in survivors. Evidence suggests early provision of rehabilitation programs reduce disability, leading to better clinical outcomes, and improves participation and quality of life of disaster victims. The World Health Organization (WHO) rehabilitation guidelines recommend implementation and access to rehabilitation during all phases of the disaster response. In line with this, there is strong consensus amongst global health authorities that medical rehabilitation should be initiated in the immediate emergency response phase, and should be continued in the community over a longer-term until treatment goals are achieved and survivors are successfully reintegrated into society. Many countries now recognize the importance of disaster planning, preparedness and management initiatives, and their disaster management capacity and collaboration has improved. Unfortunately, major disparities and gaps amongst countries exist, and those with a high disaster risk tend to have a low coping capacity, with inadequate disaster response/management plans. Many countries have limited or lack of access to appropriate services such as rehabilitation, where fragmented healthcare systems are compromised by lack of financial and political support. Rehabilitation-inclusive disaster management strategies/plans are yet to be developed in many countries, particularly in the Asia-Pacific region (where the majority of natural disasters occur). There is a concern in regards to the inadequacy of global organizational capacities and capabilities and matching of resources across the disaster cycle. In past large-scale disasters, it was beyond the capacity of many countries to have optimal disaster management and many were dependent on global humanitarian and medical assistance. This is reflected by the growing number of emergency medical teams (EMTs) responding to disasters worldwide. However, the influx of EMTs during past disasters presented immense challenges regarding response coordination and management. There was lack of standardized protocols/guidelines, coordination and evaluation mechanisms in place. This resulted in inadequate care delivery, particularly rehabilitation, with often devastating consequences for the affected individuals, families and communities. Although there have been improvements in the organization of emergency responses, care and services, this has often not extended to include rehabilitation services. Currently, there is increased scrutiny of the humanitarian response sector driven towards professionalism and accountability, to provide effective and appropriate interventions in different disaster settings. Further, there have been significant developments in international, regional and national collaboration and management capacities in disaster management, including implementation of disaster-risk reduction frameworks, quality and coordination mechanism of EMTs. One of the noteworthy developments is the establishment of the WHO-EMT Initiative and launch of EMT guidelines, including the ‘Minimum technical standards and ecommendations for rehabilitation in sudden onset disasters’. These guidelines not only classify medical response teams per their capability, but also set out the core standards for medical care of disaster victims. The WHO rehabilitation guideline provides standardized protocols for rehabilitation in future emergencies, acknowledging variations in type and patterns of injury, disease and subsequent long-term disability. It provides much needed direction for preparedness for rapid, professional, coordinated medical responses by both national and international response teams. It also provides guidance on building or strengthening the capacity of local and international EMTs within defined coordination mechanisms. A WHO registration system for all EMTs was initiated in July 2015, which enables establishment of a global registry of emergency medical response teams for deployment in future calamities. There are still immense challenges in putting these standards into practice in disaster settings. The successful implementation of these frameworks will require increased resilience of the rehabilitation community with multi-stakeholder partnerships. There is still much progress to be made on tackling the underlying drivers of disaster risk, such as poverty, climate change, rapid urbanization, and factors such as environmental degradation, poor local governance, population growth, economic development patterns, to establish a rehabilitation-inclusive disaster management model for future catastrophes. The aim is to strengthen national capacity, foster an environment of self-empowerment of EMTs and local health services, and work in rehabilitation within defined coordination mechanisms in disaster-affected area. This thesis explores the medical rehabilitation management of disaster survivors, following natural disasters. The aim was to provide evidence and systematic analyses of various rehabilitation interventions trialled in disaster survivors, in terms of their effectiveness, safety and cost-efficiency. Rehabilitation professionals’ role and gaps in evidence for medical rehabilitation in disaster management and Australian perspective were explored, specifically in the Asia-Pacific region. Further, a brief overview of current developments, challenges, and gaps in the rehabilitation-inclusive disaster management plan, including implementation of WHO guidelines, is discussed to improve care for victims of future calamities

Rehabilitation for cerebral palsy: Analysis of the Australian rehabilitation outcome dataset

Objective: To examine the outcome of inpatient rehabilitation for cerebral palsy (CP), using the Australian Rehabilitation Outcomes Center (AROC) database. Materials and Methods: De-identified data from the AROC database was analyzed for all rehabilitation admissions during 2003 – 2008, using four classes for the functional level. The outcomes included: Functional Independence Measure (FIM) scores, FIM efficiency, hospital length of stay (LOS), and discharge destination. Results: Of 141 case episodes 56.7% were female, mean age 48.5 years, 87.2% were discharged to the community and 64.5% (n = 91) were in the lowest functional classes (217, 218, and 219). The majority of CP patients were treated in the public hospital system (66.7% versus 33.3%), and had a slightly longer LOS compared with those treated in private facilities (22.6 versus 17.9 days, mean difference - 4.7 days, 95% CI - 9.2 to - 0.2, P = 0.041). The FIM for all classes (216 – 218) showed significant functional improvement during the admission (P = 0.001). As expected those in the most functionally impaired classes showed most change (FIM change: 16.6 in class 217, 15.3 in class 218). FIM efficiency was the highest in classes 217 compared to the other classes. The year-to-year trend demonstrated a mixed pattern for hospital LOS and was not significant (P = 0.492). Conclusion: The AROC dataset is a valuable research tool for describing rehabilitation outcomes. However, more specific information needs to be collected alongside the core AROC data, to allow a more meaningful evaluation of outcomes for CP rehabilitation.

Implementation of rehabilitation innovations: A global priority for a healthier society

With improved global survival rates, there is an increased demand for health-care needs for persons with noncommunicable diseases, chronic illnesses, and disaster survivors (including pandemics). Many countries struggle to meet the existing demand for health care, including rehabilitation services. Further, many persons with disability still experience socioeconomic inequity/disparities in accessing rehabilitation services. Despite increased demand for rehabilitation, many countries globally struggle to meet existing demand due to economic, social, and other barriers. The World Health Organization (WHO) initiative “Rehabilitation 2030: A Call for Action” promotes universal access to rehabilitation and prioritizes the scaling-up and strengthening of rehabilitation services and strong governance of global health partnerships and coordination between the authorities and public. The WHO launched a conceptual framework “WHO Rehabilitation in Health Systems: Guide for Action” for the development and implementation of an effective rehabilitation program within the health-care system. This pivotal resource provides detailed steps to lead governments through rehabilitation system strengthening practice specifically in low- and middle-income countries, organized in four key phases: (i) assessment of the situation; (ii) development of a rehabilitation strategic plan; (iii) establishment of the monitoring, evaluation, and review processes; and (iv) implementation of the strategic plan. The goal is to shift health trajectories onto the rehabilitation-inclusive system in a sustainable and equitable path. The article aims to provide an overview of key global initiatives in disability and rehabilitation, exclusively highlighting the WHO framework and other innovative care models for consideration

Disaster Response and Management: The Integral Role of Rehabilitation

With the increasing frequency of disasters and the significant upsurge of survivors with severe impairments and long-term disabling conditions, there is a greater focus on the importance of rehabilitation in disaster management. During disasters, rehabilitation services confront a greater load due to the influx of victims, management of persons with pre-existing disabilities and chronic conditions, and longer-term care continuum. Despite robust consensus amongst the international disaster response and management community for the rehabilitation-inclusive disaster management process, rehabilitation is still less prioritised. Evidence supports the early involvement of rehabilitation professionals in disaster response and management for minimising mortality and disability, and improving clinical outcomes and participation in disaster survivors. In the last two decades, there have been substantial developments in disaster response/management processes including the World Health Organization Emergency Medical Team (EMT) initiative, which provides a standardized structured plan to provide effective and coordinated care during disasters. However, rehabilitation-inclusive disaster management plans are yet to be developed and/or implemented in many disaster-prone countries. Strong leadership and effective action from national and international bodies are required to strengthen national rehabilitation capacity (services and skilled workforce) and empower international and local EMTs and health services for comprehensive disaster management in future calamities. This narrative review highlights the role of rehabilitation and current developments in disaster rehabilitation; challenges and key future perspectives in this area

Management of fatigue in neurological disorders: Implications for rehabilitation

This review systematically evaluates existing evidence for the effectiveness and safety of different rehabilitation interventions for managing fatigue in persons with multiple sclerosis (MS), stroke, traumatic brain injury (TBI), and Parkinson's disease (PD) for improved patient outcomes. A comprehensive literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, PubMed, and the Cochrane Library) databases for published articles up to March 1, 2018. Both reviewers applied inclusion criteria to select potential studies and extracted data independently. Overall, 56 studies (22 systematic reviews/meta-analyses, 32 randomized clinical trials, 2 controlled clinical trials) fulfilled the inclusion criteria for this review. Although existing best-evidence for many interventions is still sparse, the overall findings suggest “strong” evidence for physical activity, cognitive-educational programs, and energy conservation strategies in MS; “moderate” evidence for multidisciplinary rehabilitation in MS; home-based physical activities in stroke and TBI; hydrotherapy in MS and TBI, group-education in stroke and self-management programs in TBI; and mindfulness intervention in MS, stroke, and TBI. There was “low” evidence for exercise in PD and other physical modalities such as yoga and cooling therapy in MS, pulsed electromagnetic devices in MS and stroke; light therapy, and biofeedback in TBI. Effect of other interventions was inconclusive. Despite the available range of rehabilitation interventions for management of fatigue in neurological conditions, there is lack of high-quality evidence for many modalities. More robust research is needed with appropriate study design, timing and intensity of modalities, and associated costs

Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews

Background Multiple sclerosis (MS) is a major cause of chronic, neurological disability, with a significant long‐term disability burden, often requiring comprehensive rehabilitation. Objectives To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge. Methods We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R‐AMSTAR) tool, and the quality of the evidence for reported outcomes, using the GRADE framework. Main results Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole‐body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R‐AMSTAR criteria. Moderate‐quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate‐quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer‐term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge. Low‐qualitty evidence suggested that neuropsychological interventions, symptom‐management programmes (spasticity), whole body vibration, and telerehabilitation improved some patient outcomes. Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies. Authors' conclusions The evidence suggests that regular specialist evaluation and follow‐up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit, although the certainty of evidence varies across the different types of interventions evaluated by the reviews. Structured, multidisciplinary rehabilitation programmes and physical therapy (exercise or physical activities) can improve functional outcomes (mobility, muscle strength, aerobic capacity), and quality of life. Overall, the evidence for many rehabilitation interventions should be interpreted cautiously, as the majority of included reviews did not include data from current studies. More studies, with appropriate design, which report the type and intensity of modalities and their cost‐effectiveness are needed to address the current gaps in knowledge