2 Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.
What is the clinical and cost effectiveness of cognitive rehabilitation for people with MS?
Cognitive impairment affects 43–70% of people with MS and can affect their ability to carry out everyday activities. People with MS who have cognitive problems often engage in fewer social and vocational activities, are less likely to be in employment, can have problems carrying out routine household tasks, can have difficulties with driving and are more vulnerable to psychiatric illness. Caring for a person with MS is also likely to be more difficult if they have cognitive impairment and outcomes from research should include effect on caregivers.
Is intravenous methylprednisolone more clinically and cost effective than oral methylprednisolone in people with relapsing–remitting MS and people with secondary progressive MS with continued relapses?
It has been estimated that 8000 to 10,000 MS relapses will occur each year in the UK, which place a burden on individual patients and the NHS. The primary treatment of acute relapses is with corticosteroids, using a variety of different dosing regimens with both intravenous and oral administration. There is large variation in practice around the UK. The available evidence does not directly compare equivalent doses of oral and intravenous methylprednisolone in the subacute setting in which it is usually delivered.
What is the optimal frequency, intensity and form of rehabilitation for mobility problems in people with MS?
Reduced mobility is one of the most common problems in MS and 85% of people with MS report a gait disturbance as their main complaint. Gait is a complex function and many of the symptoms of MS, such as fatigue, weakness, spasticity and ataxia can impact on its quality. Following an assessment by a physiotherapist with expertise in MS, some gait‑related problems can be improved by the use of devices. One of the main contributors to poor gait is muscle weakness which may be primary (for example, because of the disease process) or secondary (as a result of deconditioning). The latter is common as people with MS are known to reduce their activity levels soon after diagnosis. Allowing people to regain and then maintain maximal strength is important so that they can perform their usual tasks and remain independent for as long as possible.
What non‑pharmacological interventions are effective in reducing spasticity in people with MS?
Spasticity is a common symptom affecting up to 80% of people with MS. Many people with MS also experience spasms, which are sudden, involuntary, often painful movements affecting any part of the body. Spasticity can range from a feeling of tightness or stiffness in a limb, especially the legs, which cause mild problems with walking, to a tightening of the muscles throughout the body which is so severe that the person is unable to move voluntarily and is confined to a wheelchair or bed. If left unmanaged in the severe stage, it can lead to the secondary complications of muscle shortening, permanent contractures and pain. Although medications exist which reduce spasticity, many people with MS cannot tolerate the side effects, especially of tiredness, which can compound their fatigue. This means that other, non‑pharmacological interventions need to be identified which can reduce spasticity and improve function and independence in people with MS.
Can vitamin D slow down the progression of disability in MS?
Despite considerable success with agents that substantially reduce relapse frequency in the initial inflammatory, relapsing–remitting phase, over half of people eventually develop non‑relapsing, secondary progressive MS 1 to 2 decades after the onset of relapsing–remitting MS. While a variety of symptomatic treatments is available, progression in secondary progressive MS is currently intractable, and immunomodulatory strategies used for relapsing–remitting MS have not proven effective when extended into secondary progressive MS (for example, beta interferon). Direct neuroprotection strategies (for example tetrahydrocannabinol) have also been ineffective. The critical and as yet unmet challenge therefore is to find effective and well‑tolerated treatments for secondary progressive MS.