Evidence for physiotherapy in the NICE MS … Hendrie Specialist physiotherapist in MS, Norwich...
Transcript of Evidence for physiotherapy in the NICE MS … Hendrie Specialist physiotherapist in MS, Norwich...
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