Abstract
Objectives: To assess the impact of inpatient multidisciplinary rehabilitation on a Saudi Arabian population of patients with multiple sclerosis (MS).
Methods: We retrospectively analyzed the data of patients with MS who underwent inpatient rehabilitation between 2009 and 2015 at King Fahad Medical City (KFMC). Differences in Functional Independence Measure (FIM) scores (used in rehabilitation settings to assess the functional independence of patients) and length of stay (LOS) were measured between patients of different ages, sexes, and types of MS and analyzed using the independent t-test. The Pearson correlation coefficient was used to investigate the correlation between FIM, LOS, and other variables.
Results: In total, 24 patients were identified, with an average age of 36 years. The average age at disease onset was 31 years. Disease duration ranged from 1-20 years, with a mean of 7 years. The most common type of MS was relapsing-remitting (45.8%). The mean FIM score at admission was 77.5 and at discharge 97.25. Functional independence measure gain ranged from 2-51, with a mean of 18.58. Functional independence measure efficiency (FIM gain divided by LOS) ranged between 0.09-0.95. The length of stay ranged between 21-95 days, with a mean of 37.79 days. There was a significant association between age and FIM efficiency (p=0.043).
Conclusions: Inpatient rehabilitation is an important intervention that improves the functional independence of patients with chronic MS.
Multiple sclerosis (MS) is a chronic inflammatory demyelinating autoimmune disease with a female preponderance and an estimated prevalence of 30-190 cases per 100,000 people in Europe.1 Because of its early onset, progressive course, and long survival time, MS can lead to long-term disability with a significant negative impact on personal and social life.2,3 Among neurologic diseases, it is the third most common cause of disability, with 50% of patients requiring a walking aid and 10% requiring a wheelchair within 15 years of onset; within 25 years of onset, more than 90% of patients experience significant functional impairments.4,5 Life expectancy in patients with MS is reduced by about 5-10 years compared with age-matched individuals without MS.6 Around 2 million people worldwide are affected by MS.7 In young adults, this disabling neurodegenerative disease of the central nervous system is considered the leading cause of non-traumatic disability.8 In the Middle East, the risk of MS has recently been reported to be moderate to high.9 The Kurtzke classification places the Middle East in a low-risk zone for MS; however, a moderate-to-high prevalence in areas within the region (31-55 cases per 100,000 individuals), especially among women, has recently been reported.10,11 Thus, MS represents a considerable burden to Middle Eastern countries. In the Kingdom of Saudi Arabia, the prevalence of MS is poorly documented. Reviews of epidemiologic studies have suggested that it is underdiagnosed and that its prevalence is increasing.10,11 A few studies have reported an increase in the prevalence of MS in the Kingdom of Saudi Arabia to 40/100,000 in 2008 from 25/100,000 in 1998.9,12 Likewise, there are no data on the effects of inpatient rehabilitation in the Arabian Peninsula. In the literature, common treatment strategies are based on a combination of pharmacotherapy and rehabilitation. In daily practice, multidisciplinary rehabilitation (MDR) is often recommended to patients with MS. However, the evidence regarding the outcomes of MDR is contradictory. Some trials have reported improvements in impairment and in the mental component of a health-related quality of life measure, but others have shown that MDR improves the experience of people with MS in terms of activity and participation without changing the level of impairment.13,14-16 The overall evidence on the efficacy of MDR is limited by variation in the clinical presentation of MS and problems associated with study methodology.13 In this study, we assessed the impact of short-term inpatient MDR in a Saudi-Arabian population of patients with MS to identify the clinical predictors of effective rehabilitation treatment. At KFMC, both inpatient and outpatient services are included in the neurorehabilitation program. King Fahad Medical City treats patients from all regions of the country, including those internally transferred from the National Neuroscience Institute within KFMC. The integrated neurorehabilitation program was deemed to meet the standards of the Commission on Accreditation of Rehabilitation Facilities.17
Methods
This study was conducted at the specialized neurorehabilitation unit of the Rehabilitation Hospital at KFMC after obtaining institutional review board approval. All patients with MS who were admitted to the neurorehabilitation and underwent intensive MDR between 2009 and 2015 were included in the study. Patients with an acute relapse or a prior admission for rehabilitation in the preceding 3 months were excluded. Demographic measures including age, sex, duration of disease, date of onset, and type of MS were recorded. Functional Independence Measure (FIM) scores were used to evaluate the functional status at admission (FIMa) and functional status at discharge (FIMd).18,19 Functional independence measure gain was calculated as the FIMd minus the FIMa. Functional independence measure efficiency was calculated as the FIM gain divided by the length of stay (LOS). The length of stay was measured in days. Data were collected retrospectively using the electronic chart reviewer at the hospital.
Statistical analysis
The demographic and clinical characteristics of the study’s participants were reported as means (standard deviation [SD]) for continuous variables and counts (percentages) for categoric variables. Differences in FIM scores and LOS between age, sex, and MS type groups were tested using the independent t-test. The Pearson correlation coefficient was used to investigate the correlation between FIM, LOS, and other clinical variables. All statistical analyses were performed using the Statistical Package for the Social Science (SPSS) version 22.0 (IBM Corp., Armonk, NY, USA); a 2-tailed p-value of 0.05 was considered statistically significant.
Results
In total, 24 patients with complete data were identified. There were 7 (29.2%) men and 17 (70.8%) women. Their ages ranged between 16-64 years, with a mean of 35.75±10.99 years (Table 1). There was no significant difference in FIM efficiency between the male and female patients (p=0.18).
Characteristics of the patients enrolled.
The age at disease onset ranged between 15-47 years, with a mean of 30.75±10.89 years. The correlation between FIM efficiency and age at disease onset was not significant (correlation coefficient= −0.059, p=0.78).
Disease duration ranged between 1-20 years, with a mean of 7 years (SD=5.14 days). There was a poor correlation between disease duration and FIM efficiency (correlation coefficient= −0.002, p=0.99).
Overall, 11 patients (45.8%) had relapsing-remitting MS. The remaining 13 patients (54.1%) had progressive relapsing MS: 5 patients (20.8%) had primary progressive MS; 3 patients (12.5%) had secondary progressive MS; 3 patients (12.5%) had primary relapsing MS; and the type of MS was unknown in 2 patients (8.3%). Functional independence measure efficiency was not significantly correlated with MS type (p=0.51).
The mean FIM scores at admission was 77.5±16.92 and at discharge was 97.25±17.31). The FIM gain ranged between 2-51, with a mean of 18.58±12.06. Overall, the mean FIM efficiency was 0.5±0.27, and ranged between 0.09-0.95 (Table 1).
The LOS ranged between 21-95 days, with a mean of 37.79±11.08 days. There was no significant correlation between LOS and FIM efficiency (correlation coefficient= 0.021, p=0.99).
Discussion
Strategies for the treatment of MS vary worldwide, so it is important to determine the outcomes of MS rehabilitation in specific populations. Data regarding the functional outcomes of rehabilitation in Saudi Arabian patients with MS is lacking. This may be attributable to a lack of reporting, the unavailability of comprehensive rehabilitation services, or poor awareness of rehabilitation among health-care providers and patients with MS in the country.
This research highlights the correlations between demographic features, types of disease, and functional outcomes in patients with MS undergoing inpatient rehabilitation. In our study, age was the single most significant variable and was found to have a strong association with FIM efficiency. The average age of patients was around 31 years, and 4 patients had early onset MS, i.e. disease onset before 18 years of age. None of the patients in our study had late-onset MS, i.e. disease onset after 50 years of age. This is consistent with previous studies, which have reported that the onset of MS usually begins in early adulthood, typically between the ages of 20 and 40 years.20 Multiple Sclerosis mainly affects young adults; hence, there is a need to consider rehabilitation options in the early stages of the disease, because it is a chronic disabling condition.
In the Gulf region, the female:male ratio of patients with MS varies from 0.87 in Oman to 4.3 in Saudi Arabia.21,22 However, in our study, the female:male ratio was 2.42 because our study population consisted of 17 women and 7 men. This emphasizes the need for greater resources to treat female patients, who have special requirements in our country for cultural, religious, and personal reasons. Saudi Arabian women prefer female therapists in situations where physical contact is required during treatment. Female patients also are not placed in rooms shared with male patients, and they are expected to be treated by female nurses. There are separate units and therapy areas for women in hospital settings. If there is a shortage of space, female and male patients are usually treated at different times. Their psychosocial issues are preferably addressed by female therapists or team members. The high prevalence of MS in women requires the modification of rehabilitation programs to meet the needs of female patients. Thus, the demand for female rehabilitation clinicians and health-care providers in the region remains very high.
Funcional independence measure is a reliable and valid tool to assess the functional independence of patients with MS.23 In patients with MS, the clinometric of FIM for the impact of disability is well established.24 Internationally, FIM has been validated for the documentation of everyday self-sufficiency and levels of neuromotor disability.25 Functional independence measure explores functional areas of personal care, sphincter control, mobility, locomotion, cognitive capacity, and interpersonal relationships, assigning to each a graduated score on a 7-level scale. The average FIM score at discharge of our patients was 97.25, which is fairly low compared with the FIM of 116.3 reported in a study conducted in the Czech Republic involving 35 patients.26 This discrepancy may be due to disease chronicity, because the mean duration of disease in our patients was 7 years. However, our results are comparable to Medicare data from the United States (US) on patients with MS who underwent inpatient rehabilitation.27 The FIM gain of 18.58 points in our study is also comparable with US Medicare data reported in 2012, which showed a FIM gain of 21.3 points. Similarly, the FIM score at discharge was 82 points in the Medicare patients, whereas it was 97.25 points in our patients. The comparatively high FIM scores in our patients may be due to the fact that our patients had a fairly long LOS, i.e. 38 days, during inpatient rehabilitation, whereas the Medicare patients had an inpatient rehabilitation stay of 15 days. In contrast, in a British study involving 41 patients who underwent rehabilitation, the patients stayed 10 days longer than in our study.28 Given the variation in LOS reported globally, FIM efficiency was included as an outcome measure in our study to reflect the FIM gain adjusted to the LOS; however, we were unable to find any international comparisons for the FIM efficiency of MS patients. Even in our study, sex, type of MS, disease duration, age of onset, and LOS showed no significant association with FIM efficiency. Considering the small number of patients included in our study (n= 24), our results are poorly comparable with the Medicare data, which was collected from 4,669 patients; however, our analyses may serve as a benchmark for future studies.29
Rehabilitation plays a vital role in improving the physical and psychologic abilities of patients with MS. Rehabilitation focuses on reducing symptoms and limitations at the level of activity and participation. These interventions, which improve the quality of life of patients with MS, also emphasize personal and environmental factors.29 Favorable outcomes of inpatient rehabilitation in patients with MS have been confirmed by some studies.28,30 There are also studies that state that short-term improvements in clinical and functional outcome measures can be achieved with intensive inpatient rehabilitation programs.31
However, the unique aspect of our study was that most of the patients had chronic MS and still showed considerable functional gains. The mean duration of disease was 7 years, and most of our patients had relapsing-remitting MS.
In conclusion, inpatient rehabilitation is an important intervention that improves functional independence in patients with chronic MS. Data regarding the use of FIM efficiency as an outcome measure for patients with MS is scarce. Functional independence measure efficiency can be used to demonstrate functional gains in relation to LOS; however, further studies on a larger scale are necessary both nationally and internationally to confirm these findings.
Footnotes
Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.
- Received July 24, 2017.
- Accepted January 10, 2018.
- Copyright: © Neurosciences
Neurosciences is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work.
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