Barriers and Facilitators Related to Rehabilitation Stays in Multiple Sclerosis: A Qualitative Study

Exploring Consumer Experiences of Barriers and Enablers to Accessing Rehabilitation That Meets Their Needs: The Rehabilitation Choices Study, Part 2-Consumer Perspectives

INTRODUCTION

Improved access to rehabilitation is highlighted as a key pathway to achieving the World Health Organisation's (WHO) goal of ensuring healthy lives and promoting well-being for all (Sustainable Development Goal 3). This article is the second in a two-part series outlining the findings from the Rehabilitation Choices study, which aimed to identify how health professionals and consumers in Australia are informed to make decisions about rehabilitation, and their experience with barriers and enablers to accessing that rehabilitation. In this study, we present the perspectives of consumers with different health conditions and a range of experiences with rehabilitation services.

METHODS

This was a qualitative study using focus groups and semi-structured interviews. People with self-reported lived experience of rehabilitation and carers were recruited using maximum variation sampling. Thematic analysis of data was conducted using an inductive approach.

RESULTS

Fifty-six consumers with diverse lived experiences of rehabilitation (19-80 years, 49 patients, 7 carers) participated in focus groups and interviews to discuss how they sourced information about rehabilitation and their experiences of what made it hard or easy to access rehabilitative care to meet their needs. Four themes were produced from the data: (1) service-centricity of options limits access, (2) access is the patient's responsibility, (3) enabling decision-making about rehabilitation with appropriate information and (4) provision of a psychologically safe environment.

CONCLUSIONS

Any planned (re)design of services to improve consumer access to rehabilitation should consider the themes identified in this study. This will ensure that consumers are provided with rehabilitation options that suit their holistic and unique needs beyond consideration of their medical diagnoses, and are actively supported to navigate this access, provided with information to help them make informed choices and provided a psychologically safe environment to engage effectively with rehabilitation.

PATIENT OR PUBLIC CONTRIBUTION

Three consumer research partners with lived experience of rehabilitation as patients or carers were core team members. They were involved in the design and implementation of the recruitment and communications strategies, design of the interview approach and discussion guide, contributed to the interpretation and contextualisation of findings and writing of this manuscript and are included as co-authors (A. O., T. W. and S. W.).

Awareness and Utilization of Public Physiotherapy Health Care Services to Support People With Multiple Sclerosis: A Health Care Service Audit

BACKGROUND

To maximize functioning and well-being in people with multiple sclerosis (MS), physiotherapy consultation is recommended at the point of diagnosis and throughout the disease course. We wanted to determine whether patients with MS being managed through a large metropolitan hospital in Australia accessed physiotherapy input as part of their MS management consistent with evidence-based recommendations and to identify patients' self-reported physiotherapy requirements, including symptom management, information needs, and service delivery preferences.

METHODS

Surveys were sent to 597 MS clinic patients, and 160 responded. Data were analyzed using descriptive methods to derive frequencies and percentages. The survey consisted of 16 questions plus 2 optional questions related to sociodemographics (age and postcode).

RESULTS

Of 160 respondents, 142 completed all 14 nonoptional questions. One-third of participants (n = 53) were aware of the hospital MS clinic physiotherapy services, with 21.3% (n = 34) saying that they had accessed these services. Conversely, 40.1% of respondents (n = 61) reported having consulted a private physiotherapist. Combined, 52% of respondents reported seeing a physiotherapist. There was a clear preference (94.7%; n = 144) for access to the MS clinic physiotherapy service. The presence of at least 1 current MS-related physiotherapy problem was reported by 82.2 2% of respondents (n = 125). The top ways to access MS-related information were via a specialist MS website (57.6%) and a mobile app (55.6%).

CONCLUSIONS

There is an unmet need for physiotherapy, and many participants may have foregone services due to unawareness. Improved awareness and uptake of physiotherapy at the point of diagnosis is needed to maximize functioning and well-being in people with MS.

Fall Assessment and Monitoring in People With Multiple Sclerosis: A Practical Evidence-Based Review for Clinicians

Purpose of Review

Falls occur in more than half of all people with multiple sclerosis (MS) but tend to be underdiagnosed and underreported in clinical encounters. This narrative review aims to summarize evidence-based approaches for evaluating fall risk and proven treatment strategies to reduce falling in people with MS to improve care for people with MS and to enhance interprofessional care coordination between treating neurologic and physical therapy (PT) teams.

Recent Findings

Screening not just for falls but for near-falls as well because fear of falling can improve fall assessment and identify patients who may benefit from fall prevention interventions. A number of barriers, including time constraints during visits and the fallacy that falling is inevitable in MS, can limit clinician awareness about patient falls and delay timely referral to PT. Consultation with physical therapists for individualized fall prevention treatment can reduce risk of falling. Interventional studies have also shown that PT-guided exercise programs improve balance confidence in people with MS. However, people with MS are often under-referred to PT by treating clinicians.

Summary

A clinical approach is provided to summarize practical, accessible, evidence-based, low-burden measurements and interventions likely to improve ascertainment of patients at risk of falling and optimize timely PT referral and treatment.

A qualitative exploration of the rehabilitation perceptions and experiences of persons with early multiple sclerosis

BACKGROUND

Since the advent of disease-modifying therapies (DMTs), people with MS are living longer. The management of MS requires use of DMTs, symptom management, and prevention for those with access to these aspects of health care. Although DMTs are used as part of early intervention to manage disease pathophysiology in those with MS, physical rehabilitation still focuses on symptomatic management of MS (tertiary prevention) and has not embraced a primary or secondary prevention approach to holistically manage MS. Although rehabilitation has been found to be beneficial for people with MS, there is currently limited information for persons in their early years of MS diagnosis. More importantly there is limited engagement of persons with early MS in rehabilitation care. Thus, the purpose of this study was to elucidate the perceptions of people living with early MS and their overall experiences with physical rehabilitation for MS management.

METHODS

The study team used semi-structured interviews to collect qualitative data to ascertain the experiences and perceptions of 15 persons with early MS who were within 5 years of diagnosis (mean age 36.5 ± 10.4 years). Using a phenomenological approach, the researchers sought to understand the lived experiences of 15 people living with early MS. Using inductive thematic analysis, authors coded each interview separately and arrived at themes with consensus.

RESULTS

Our study discovered six main themes and several subthemes offering insight into the lived experiences of the participants. Themes uncovered included: insight to condition, awareness of rehabilitation, resource availability, information seeking, clinician expertise in MS, and therapeutic use of self.

CONCLUSIONS

Our study offered a small but poignant glimpse into the lived experiences of people living with early MS. There is still poor public awareness of MS-specific rehabilitation and its benefits for people with early MS. People with early MS seek information about their diagnosis but information and resources that are reliable and easily accessible are still needed, especially from their neurologists, to improve engagement in MS-specific rehabilitation. More research exploring these experiences and more diversity in the participant pool would lead to best practices in physical rehabilitation.

The role of machine learning in developing non-magnetic resonance imaging based biomarkers for multiple sclerosis: a systematic review

BACKGROUND

Multiple sclerosis (MS) is a neurological condition whose symptoms, severity, and progression over time vary enormously among individuals. Ideally, each person living with MS should be provided with an accurate prognosis at the time of diagnosis, precision in initial and subsequent treatment decisions, and improved timeliness in detecting the need to reassess treatment regimens. To manage these three components, discovering an accurate, objective measure of overall disease severity is essential. Machine learning (ML) algorithms can contribute to finding such a clinically useful biomarker of MS through their ability to search and analyze datasets about potential biomarkers at scale. Our aim was to conduct a systematic review to determine how, and in what way, ML has been applied to the study of MS biomarkers on data from sources other than magnetic resonance imaging.

METHODS

Systematic searches through eight databases were conducted for literature published in 2014-2020 on MS and specified ML algorithms.

RESULTS

Of the 1, 052 returned papers, 66 met the inclusion criteria. All included papers addressed developing classifiers for MS identification or measuring its progression, typically, using hold-out evaluation on subsets of fewer than 200 participants with MS. These classifiers focused on biomarkers of MS, ranging from those derived from omics and phenotypical data (34.5% clinical, 33.3% biological, 23.0% physiological, and 9.2% drug response). Algorithmic choices were dependent on both the amount of data available for supervised ML (91.5%; 49.2% classification and 42.3% regression) and the requirement to be able to justify the resulting decision-making principles in healthcare settings. Therefore, algorithms based on decision trees and support vector machines were commonly used, and the maximum average performance of 89.9% AUC was found in random forests comparing with other ML algorithms.

CONCLUSIONS

ML is applicable to determining how candidate biomarkers perform in the assessment of disease severity. However, applying ML research to develop decision aids to help clinicians optimize treatment strategies and analyze treatment responses in individual patients calls for creating appropriate data resources and shared experimental protocols. They should target proceeding from segregated classification of signals or natural language to both holistic analyses across data modalities and clinically-meaningful differentiation of disease.

Experiences of persons with multiple sclerosis with rehabilitation-a qualitative interview study

Background

Managing multiple sclerosis (MS) includes different treatment approaches. Rehabilitation is a key strategy in MS for improving functioning, activity and participation. As part of a larger study on overall patient experiences with different treatment approaches, this study aims to give an overview of different patients’ experiences and perspectives on inpatient rehabilitation in MS.

Methods

We conducted problem-centered interviews in 50 persons with MS in Germany, of whom most had relapsing–remitting MS. We used the maximum variation sampling method during recruitment. Data were analyzed thematically.

Results

As a result of the analysis, three major themes were identified: 1) factors contributing to the decision-making concerning rehabilitation, 2) experience with the rehabilitation setting, 3) benefits of rehabilitation treatments. The treating physicians’ attitude had a major impact on the decision to either opt for rehabilitation or not. Setting goals prior to rehabilitation was given a high priority. Exchanging experiences with other persons with MS presented a major benefit from rehabilitation while for some being separated from regular daily life resulted in a more ambiguous attitude ranging from appreciation of escaping daily hassles to substantial behavioral change management.

Conclusion

Patients reported various experiences in the process of decision-making with regard to rehabilitation. Physicians´ advice, goal setting and the selection of the most suitable rehabilitation clinic were considered most relevant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08150-8.

Caregiver Involvement in MS: Duty or Disruption?

Multiple sclerosis (MS) is a complex condition with numerous physical, cognitive and emotional symptoms. These may necessitate significant, permanent lifestyle changes for people with multiple sclerosis (PwMS) and their caregivers and families, meaning it is important in contemporary neurological practice to consider including families and/or caregivers in the management of MS. However, existing evidence suggests that family involvement is not always beneficial; for example, it can exert either a strong positive or negative influence on the ability of PwMS to achieve optimal outcomes from their treatment and disease management. This paper, based on a live debate between neurologists and PwMS, examines the current perceptions on constructive involvement of families and caregivers in consultations for and management of MS, and reveals several areas where additional studies are warranted. Shared decision-making in MS has historically been a collaboration solely between healthcare professionals (HCPs) and PwMS, but PwMS are now more frequently being accompanied to appointments by a support person. This paper encourages HCPs to understand the dynamics between PwMS and their support person, and to individualize consultations and information accordingly. Family and caregiver involvement in the provision of care for PwMS needs to be for the benefit of, and at the discretion of, the PwMS. Support for families of PwMS, although important, may be more effectively and appropriately delivered through other channels outside of the clinical setting. Educating HCPs on the current patient experience to enable them to provide improved personalized care will ensure a mutualistic, patient-centred relationship with PwMS, which will help to optimize outcomes. Communication tools may also facilitate these interactions.

Evaluation of the quality of the care pathway for patients with multiple sclerosis in France: Results of an original study of a cohort of 700 patients

INTRODUCTION

Evaluating the quality of the care pathway for patients with chronic diseases, such as multiple sclerosis (MS), is an important issue. Process indicators are a recognized method for evaluating professional practices. However, these tools have been little developed in the field of MS, and few data are available. The aim of this study was to describe, retrospectively, with validated indicators, the quality of the care pathway in a population-based cohort of 700 patients with the first manifestations of the disease occurring between January 1, 2000 and December 31, 2001 and during the first 10 years of disease.

METHOD

This assessment was based on 48 indicators specific to MS. The information required for the calculation of each indicator was collected from the source files of the 700 patients of the cohort.

RESULTS

Data for the 10 years of follow-up were collected for 80% of the patients. In total, 36 indicators were calculated. These results reveal that there is room for improvement, particularly in terms of the initial assessment, access to ophthalmological evaluation, employment, obtaining an evaluation of the need for rehabilitation and access to such care.

CONCLUSION

The results of this survey provide access to unprecedented new data in France, that professionals and patients can appropriate to improve the targeting of actions, to improve the quality of care further for patients with MS in France. We propose to continue this process by submitting, for discussion, a targeted list of updated indicators relating to changes in guidelines, and in issues concerning the quality of patient management.

Identifying Barriers to and Facilitators of Health Service Access Encountered by Individuals with Multiple Sclerosis

Background

The symptoms of multiple sclerosis (MS) can be diverse, complex, and progressive, creating a need for frequent and long-standing health care services. The purpose of this scoping review was to identify the barriers people with MS encounter when attempting to access multidisciplinary health services and the reported facilitators for better access to health services.

Methods

The MEDLINE, Embase, and CINAHL databases were searched, without date or geographic restrictions, using the following terms: multiple sclerosis, health services accessibility, health care access, health care delivery, and delivery of health care. After screening based on exclusion criteria, 23 articles were included in the final review.

Results

Five main themes were identified as barriers and facilitators to accessing health services: 1) information (information available to people with MS, health care provider knowledge of and familiarity with MS), 2) interactions (interactions between health care providers and people with MS, social networks and support of people with MS, collaboration among health care providers), 3) beliefs and skills (personal values and beliefs, perceived time to travel to and attend appointments, and self-assessment of symptoms and needs of people with MS), 4) practical considerations (wait times, physical barriers, affordability of services), and 5) nature of MS (complexity and unpredictability of disease symptoms).

Conclusions

People with MS and their health care providers may benefit from structured and comprehensive MS-specific education to address barriers to accessing health care services. The education can ultimately facilitate the process of addressing unmet health care needs and contribute to a greater quality of life for people with MS.

'It struck at the heart of who I thought I was': A meta-synthesis of the qualitative literature examining the experiences of people with multiple sclerosis

Background

People with multiple sclerosis (MS) have varied experiences and approaches to self‐management. This review aimed to explore the experiences of people with MS, and consider the implications of these experiences for clinical practice and research.

Methods

A meta‐synthesis of the qualitative literature examining experiences of people with MS was conducted using systematic searches of ProQuest, PubMed, CINAHL and PsycINFO. We incorporated feedback from team members with MS as expert patient knowledge‐users to capture the complex subjectivities of persons with lived experience responding to research on lived experience of the same disease.

Results

Of 1680 unique articles, 77 met the inclusion criteria. We identified five experiential themes: (a) the quest for knowledge, expertise and understanding, (b) uncertain trajectories (c) loss of valued roles and activities, and the threat of a changing identity, (d) managing fatigue and its impacts on life and relationships, and (f) adapting to life with MS. These themes were distributed across three domains related to disease (symptoms; diagnosis; progression and relapse) and two contexts (the health‐care sector; and work, social and family life).

Conclusion

The majority of people in the studies included in this review expressed a determination to adapt to MS, indicating a strong motivation for people with MS and clinicians to collaborate in the quest for knowledge. Clinicians caring for people with MS need to consider the experiential and social outcomes of this disease such as fatigue and the preservation of valued social roles, and incorporate this into case management and clinical planning.

Factors Associated with Postrelapse Rehabilitation Use in Multiple Sclerosis: A Pilot Survey

Background

Most people with multiple sclerosis (MS) have periodic and unpredictable relapses as part of their disease course. Relapses often affect functional abilities, resulting in diminished productivity and lower quality of life. Considering the effects, rehabilitation can play an important role in facilitating recovery; yet, the current literature suggests a lack of postrelapse rehabilitation services use. This study aims to document postrelapse rehabilitation services use and estimate the extent to which predisposing characteristics, perceived need, and enabling resources were associated with postrelapse rehabilitation services use in adults with MS.

Methods

This cross-sectional study used convenience sampling, and data from 73 adults with MS who recently had a relapse in the United States and Canada were analyzed.

Results

A total of 25 participants (34.2%) reported using postrelapse rehabilitation services. The regression model identified three variables associated with postrelapse rehabilitation services use: age (odds ratio [OR], 1.075), self-reported quality of life (considerably affected by the most recent relapse [OR, 5.717]), and presence of helpful health care providers (for obtaining postrelapse rehabilitation services [OR, 5.382]).

Conclusions

Most participants experienced a range of symptoms or limitations because of their most recent relapse, affecting their daily activity and quality of life. However, only one-third of the participants reported using postrelapse rehabilitation services, which focused on the improvement of their physical health. Regression modeling revealed that three population characteristics of the Andersen Behavioral Model of Health Services Utilization were associated with postrelapse rehabilitation services use.

Rehabilitation use in multiple sclerosis: Do illness representations matter?

OBJECTIVES

Multidisciplinary rehabilitation improves illness outcomes and is recommended in clinical guidelines for multiple sclerosis (MS). However, many people with MS do not make use of rehabilitation. We do not know much about the barriers to the use of rehabilitation in MS, but in other patient groups, illness representations have proven to be predictors of service utilization. Therefore, the aim of our study was to explore whether, in patients with MS, illness representations are associated with self-reports of rehabilitation use in the past and the intention to use rehabilitation in the future, beyond sociodemographic and illness-related factors.

MATERIALS AND METHODS

Patients were recruited in a cross-sectional nationwide online survey in Germany. Hierarchical binary logistic regression analysis was used to analyze whether illness representations are associated with the use of rehabilitation in the past and the intention to use rehabilitation in the future, over and above socio-demographic and illness-related variables.

RESULTS

There were 590 patients, who had MS, participating in the study. Illness representations were correlated to both outcome variables beyond sociodemographic and illness-related factors: The probabilities of having the intention to use rehabilitation and of making using of rehabilitation were higher in patients who believed that their MS was controllable by treatment and perceived that their MS would have severe consequences.

CONCLUSIONS

Our data suggest that addressing patients' illness representations may facilitate the intention to use and the use of multimodal rehabilitation, contributing to better illness outcomes.

Comparison of attitudes toward disability and people with disability among caregivers, the public, and people with disability: findings from a cross-sectional survey

Background

A negative attitude toward disability is one of the potential barriers for people with disability (PWD) to achieve social equality. Although numerous studies have investigated attitudes toward disability, few have evaluated personal attitudes toward disability among PWD, and made comparisons with attitudes of healthy respondents. This study was to investigate and compare the attitudes of PWD, caregivers, and the public toward disability and PWD in China, to identify discrepancies in attitude among the three groupsand to examine potential influencing factors of attitude within each group.

Methods

A cross-sectional study was conducted among 2912 PWD, 507 caregivers, and 354 members of the public in Guangzhou, China. Data were collected on participants’ socio-demographic information and personal attitudes toward disability using the Attitude to Disability Scale (ADS). ANOVA and ANCOVA were applied to compare the level of attitude among the three groups. Simple and multiple linear regression analyses were used to investigate the relationship between each background factor and attitude within each group.

Results

Over 90 % of caregivers were PWD’s family members. After controlling the socio-demographic characteristics, caregivers had the lowest total scores of ADS (caregivers: 47.7; PWD: 52.3; the public: 50.5). Caregivers who had taken care of PWD for longer durations of time had a more negative attitude toward disability. In contrast, PWD who had been disabled for longer times had a more positive attitude toward disability.

Conclusions

The current national social security system of China does not adequately support PWD’s family-member caregivers who may need assistance coping with their life with PWDs. More research is needed, and the development of a new health-care model for PWD is warranted.

Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study

Background

Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied.

Objective

The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients.

Methods

This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months.

Results

Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (−4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant.

Conclusions

This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.

Evaluation of an integrated multidisciplinary approach in multiple sclerosis care: A prospective, randomized, controlled study

BACKGROUND

Disabled multiple sclerosis (MS) patients often need intervention of multiple specialists, resulting in a complex organization of care. How this multidisciplinary care should be organized and structured has not been studied.

OBJECTIVE

The objective of this article is to address the effectiveness of an integrated multidisciplinary approach versus usual care in MS patients.

METHODS

This is a prospective, randomized, controlled, monocentric clinical trial in MS patients. Two treatment strategies were compared: (i) an integrated multidisciplinary (IMD) approach, consisting of a half-day individually tailored comprehensive assessment in the MS clinic; and (ii) a standard care. The primary outcome was the impact of the strategy on quality of life (QoL) measured using the MSIS-29 scale at inclusion and after six months.

RESULTS

Fifty MS patients were included. Median MSIS 29 score decreased over six months in the control group (-4.89) and increased in the IMD group (+2.00), with a significant difference between the two groups (p = 0.03). However, in the multivariate analysis, after adjustment of HAD-D and INTERMED score, this difference was no longer significant.

CONCLUSIONS

This prospective, randomized study is the first attempt to evaluate the multidisciplinary approach in MS patients. The results show that, contrary to our expectations, an integrated multidisciplinary approach is not superior to usual care on QoL.