26 June 2004
National Collaborating Centre for Chronic Conditions - National Government Agency [Non-U.S.]
Summary,

GUIDELINE OBJECTIVE(S)

* To serve as a guideline for the National Health Service (NHS) in England and Wales
* To ensure that people with multiple sclerosis benefit from a coherent and consistent response from services, to minimise their problems as far as can be achieved
* To help health care professionals provide optimal services for those with multiple sclerosis by:
o Providing individual clinicians with a set of explicit statements on the best way to manage most common clinical problems to maximise the effectiveness of the service
o Providing commissioning organisations and provider services with specific guidance on the best way to organise complex services, to maximise efficiency and equity

TARGET POPULATION

Adults of all ages with multiple sclerosis

INTERVENTIONS AND PRACTICES CONSIDERED

General Management Principles

1. Effective communication
2. Offering emotional support
3. Encouragement of autonomy/self-management
4. Offering support to family and carers
5. Multiple sclerosis-specific assessment and measurement
6. Team approach to rehabilitation and goal-setting that covers both short-term specific actions and longer-term outcomes
7. Involvement of specialist services (particularly neurological services, but also dietetics, liaison psychiatry, continence advisory and management services, pain management services, chiropody and podiatry, and ophthalmology services).
8. Ensuring timeliness of all interventions

Diagnosis

1. History
2. Physical examination
3. Radiologic/Laboratory tests as appropriate, including:
* Magnetic resonance scan
* Analysis of cerebrospinal fluid
* Computed tomography brain scan
4. Use of McDonald Criteria (see Appendix G in original guideline document)

Treatment of Acute Episodes

1. High-dose corticosteroids (e.g. oral or intravenous methylprednisolone)
2. Patient education and supportive services (e.g. equipment, personal care)
3. Referral to neurological rehabilitation
4. Interventions affecting disease progression:
* Interferon beta
* Glatiramer acetate
* Linoleic acid
5. The following treatments should not be used except in specific circumstances:
* Azathioprine
* Mitoxantrone
* Intravenous immunoglobulin
* Plasma exchange
* Intermittent (4-monthly) short (1-9 days) courses of high-dose methylprednisolone
6. The following treatments should not be used:
* Cyclophosphamide
* Anti-viral (for example, acyclovir, tuberculin)
* Cladribine
* Long-term treatment with corticosteroids
* Hyperbaric oxygen
* Linomide
* Whole-body irradiation
* Myelin basic protein (any type)
7. Altering risk of relapse
* Immunisation against influenza

8. Offering advice/support concerning pregnancy and stress, including surgical stress and anesthesia

Rehabilitation and Maintenance of Functional Activities

1. Identifying and treating any treatable underlying impairments
2. Patient/Carer(s) education/training regarding mobility, activities of daily living, assistive equipment, adaptations, services available
3. Altering environment as needed
4. Physiotherapy treatments

Management of Specific Impairments

See the "Major Recommendations" section of this summary for a complete discussion of interventions recommended for fatigue, bladder dysfunction, urinary tract infections, bowel problems, weakness and cardiorespiratory fitness, spasticity, spasms and joint contractures, ataxia and tremor, sensory losses, visual problems, pain, cognitive losses, emotionalism, depression, anxiety, swallowing difficulties, speech difficulties, sexual dysfunction, pressure ulcers, and other treatments including complementary therapies.

MAJOR OUTCOMES CONSIDERED

* Disease symptoms
* Activities of daily living
* Relapse rate
* Disease progression
* Sensitivity and specificity of diagnostic tests
* Diagnostic accuracy
* Magnetic resonance imaging outcomes
* Incidence of side effects
* Quality of life
* Patient and carer costs
* Cost-effectiveness