Evidence for physiotherapy

in the NICE MS Guidelines

2014

Wendy Hendrie

Specialist physiotherapist in MS, Norwich

Member of NICE MS Guideline Development Group

Aims

Overview of recently published NICE MS guidelines

Implications for PT management of MS

Effectiveness of current treatment model of

short-term intervention and discharge

Implications for future research

Health and safety warning

Find the physio ….

… or MDT

Aims

Overview of recently published NICE MS guidelines

Implications for PT management of MS

Effectiveness of current treatment model of

short-term intervention and discharge

Implications for future research

2014 v 2003

2014

Only covers issues

raised by stakeholders

– 18 questions

Does not map out a

service model

2003

Covers all components

of health care along

MS journey

Describes best

practice and a model

of care

2014 v 2003

2014

Limited to scope of

guideline

RCTs - GRADE

No consensus expert

opinion

MS only

2003

Full description of

service

Evidence graded A-D

Consensus expert

opinion

Similar conditions

2014 v 2003

2014

Short and fragmented

Medical

Useful or useable?

2003

Full and coherent

MDT

Useful and useable

2014 NICE MS Guidelines …

Guideline Sections

Sec 5. Diagnosing MS

Sec 6. Coordination of care

Coordinated MDT approach with HCP who have expertise in managing MS *

Sec 7. Providing information and support

PwMS management plan including who to contact if their symptoms change

Guideline Sections

Sec 8. Modifiable risk factors for relapse or progression of MS

Exercise is good for people with MS *

Sec 9. Pharmacological management of MS symptoms

Trigger factor list for spasticity *

Self-management of drug titration *

Guideline Sections

Sec 10. Non-pharmacological management of MS

symptoms

Fatigue – exercise can reduce fatigue *

Mobility – exercise can improve mobility

Pain – treat posture related pain

Spasticity – no recommendations

Ataxia and tremor – no recommendations

Find the physio ….

… in the

smallprint!

Guideline Sections

Sec 11. Comprehensive review

Annual *

Length of interventions

Sec 12. Treatment of acute relapses with

steroids

Relapses – may need rehabilitation

Sec 13. Other treatments

Aims

Overview of recently published NICE MS guidelines

Implications for PT management of MS

Effectiveness of current treatment model of

short-term intervention and discharge

Implications for future research

Fatigue (Section 10)

14 RCTs of physical interventions

Resistance, aerobic, balance (Yoga, Wii), massage, electromagnetic field, vestibular rehab

5 cognitive / psychological

CBT, fatigue management, mindfulness, motivational interviewing

Fatigue (Section 10)

Recognition that exercise improves fatigue

Supervised exercise programmes

Moderate progressive resistance training

combined with CBT, EDSS ≥ 4 (Carter et al, 2014 – EXIMS)

Aerobic / balance / Yoga / vestibular exs

Encourage exercise after treatment ends

Refer to exercise referral schemes

Mobility (Section 10)

25 RCTs

Aerobic, neurorehab, resistance, balance,

stretching, task-orientated, whole-body vibration,

Yoga, vestibular rehab

Mobility (Section 10)

Access to assessment and establish goals with

expert in MS

Supervised exercise programmes

Moderate progressive resistance training

Aerobic exercise, vestibular rehab

Encourage exercise after treatment ends

Refer to exercise referral schemes

Fatigue and Mobility

“Consider vestibular rehabilitation for … fatigue

or mobility problems associated with limited

standing balance” (Hebert et al, 2011)

“If more than one of the interventions

recommended for mobility or fatigue are suitable,

offer treatment based on which the person

prefers and whether they can continue the

activity when the treatment programme ends”

Pain (Section 10)

“Be aware the musculoskeletal pain is common in

people with MS and is usually secondary to problems

with mobility and posture. Assess musculoskeletal

pain, offer treatment to the person and refer them

as appropriate”

Annual review (Section 11)

Comprehensive

Completed by one or more health professionals

Asks about social activity and participation /

carers needs

Refer identified issues to neuro MDT

Who does it, where or how?

Relapse management (Section 12)

“Identify whether the person with MS having a

relapse or exacerbation needs additional symptom

management or rehabilitation”

Implications for PT management of MS

Expertise in MS

Anti-spasticity drug self-management

(Supervised and self-managed long-term) exercise

is good for people with MS

Implications for PT management of MS

Competencies, training, education

Prescriber / supplementary prescriber

Group work, partnerships with local gyms, long-

term support / supervision

Aims

Overview of recently published NICE MS guidelines

Implications for PT management of MS

Effectiveness of current treatment model of

short-term intervention and discharge

Implications for future research

Effectiveness of current treatment model of

short-term intervention and discharge

Acknowledgement of importance of long-term

engagement with activity

People need long-term support /supervision

– electronic contact, groups, education

LTC register, self-referral, no discharge?

Comprehensive review (Section 11)

Length of interventions

“Determine how often person with MS will be

seen based on their needs and those of their

family and carers and the frequency of visits

needed for different types of treatment such as

rehabilitation”

Aims

Overview of recently published NICE MS guidelines

Implications for PT management of MS

Effectiveness of current treatment model of

short-term intervention and discharge

Implications for future research

Research recommendations

Spasticity

Ataxia

Mobility

Heat-sensitive fatigue

Research questions - spasticity and

ataxia

What non-pharmacological interventions are

effective in reducing spasticity in MS?

What non-pharmacological interventions are

effective in reducing ataxia in MS?

Research questions – mobility and heat-

sensitive fatigue

What is the optimal frequency, intensity and form

of rehabilitation for mobility problems in MS?

What non-pharmacological interventions are

effective in reducing heat-sensitive fatigue in

people with MS?

Research

Low quality of research

Participant numbers

Complex interventions / blinding

Barriers

GRADE quality tool

Should we use inappropriate trial designs simply

to satisfy NICE?

Wendy goes to NICE

A flawed process?

Limited scope

No consensus / steering group

No MS charity on GDG

GDG dominated by medics

RCT evidence – GRADE

Failure to respond fully to 300 pages of comments

Failure to learn lessons from the past

Why a re-write of 2003?

Throwing the baby out with the

bathwater

2014 MS Guidelines - useful or useable?

2003 – Pragmatic, inclusive, comprehensive. Best

practice model. Some of the strongest

recommendations based on what the group knew

to be true.

2014 – Restricted, medical, fragmented. Not a

service model. Recommendations based on

‘strong’ RCT evidence.

Things left out

General principles of care

Mobility – wheelchairs

Sensory, visual deficits

Contracture

Weakness and deconditioning

Functional and vocational activities, ADL, leisure,

social participation

NICE – doing its job?

“NICE’s role is to improve outcomes for people

using NHS services”

“NICE guidance sets the standards for high

quality health care”

Where do we go from here?

Professional tasks

Describe what constitutes ‘expertise in MS’

Talk about research

Extending scope of practice – prescribing

Benchmark our services – audit tool

Look at new ways of working

Where do we go from here?

Political tasks

Tell commissioners what we do

Encourage NICE to look again at their process

Thank you for listening