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The recent debate in the United Kingdom over whether or not β-interferon and glatiramer acetate should be prescribed on the National Health Service for people with multiple sclerosis has focused the attention of the media, health services, and the business community in a way never previously experienced. However, the use of drugs which have a partial effect on disease activity is just one component of the active management of this complex disease. Multiple sclerosis has wide ranging physical and psychosocial consequences, which may have an enormous long term impact on almost every aspect of the daily lives of people with the disease and their families. In providing an adequate service it is therefore crucial to focus not only on the role of immunomodulatory drugs, but also on the many rehabilitation strategies which aim to improve the quality of life of people with multiple sclerosis. Drug therapy and rehabilitation strategies should be viewed as partners rather than competitors in the allocation of resources. Evidence based medicine requires resources to be allocated to interventions of proved effectiveness. It is therefore timely that the paper by Wileset al in this issue (pp174–179)1 provides evidence of the effectiveness of a very commonly used rehabilitation intervention, physiotherapy.
Given that physiotherapy is so commonly used in multiple sclerosis, it is perhaps difficult to understand why such a paucity of scientific evidence exists to either support or refute its effectiveness. In part, this is because studies of this type are difficult to plan and to implement. This controlled randomised cross over study by Wiles et al 1shows that rigorous methodology is possible. Of importance, it provides evidence to support the widely held belief (by both clinicians and patients) that specialist neurological physiotherapy helps to improve mobility in people with multiple sclerosis. The next step is to understand the mechanism by which these strategies work.
Physiotherapy is just one component within the comprehensive model of care designed to improve the quality of life of people with multiple sclerosis. It is encouraging that in the past few years two randomised controlled studies have been published to demonstrate the positive impact that multidisciplinary packages of care can have on the daily life of the person with multiple sclerosis.2 3While recognising that scientifically credible studies remain few in number, it is hoped that this gradual accumulation of evidence will help to reduce the negative preconceptions, which have tended to persist about the effectiveness and validity of rehabilitation in multiple sclerosis; and will positively influence the allocation of funds to these areas.
A review of the allocation of resources for the management of multiple sclerosis is clearly needed. A recent study investigating the level of community services in the United Kingdom showed that the provision of services seemed to be simply a matter of chance, providing support for the often expressed dissatisfaction by people with multiple sclerosis about the services they receive.4 It is hoped that national guidelines and standards of care will help to improve this situation. Currently guidelines for the management of multiple sclerosis are being drafted by the National Institute for Clinical Excellence. Their development and the future allocation of resources will depend heavily on the available evidence base. Further rigorous evaluation of rehabilitation interventions such as physiotherapy is therefore clearly necessary. In undertaking such evaluation there is a need to broaden the research methodologies used, to tap the experience and views of people with multiple sclerosis, their families, and clinicians who work within this field. The “New NHS” claims to positively promote user involvement in the development of health services. This is a golden opportunity for this principle to be put into action; to provide the much needed impetus to improve the provision of services to people with multiple sclerosis. We await to see whether this is an opportunity seized...or one that is lost.
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