The organisation of physiotherapy for people with multiple sclerosis across Europe: a multicentre questionnaire survey

In the literature, several studies have evaluated the accessibility and use of physiotherapy within individual countries from the perspective of people with MS [13–17]. No studies to date have investigated the organizational aspects of PT in MS, based on professional opinion, nor compared services between countries. This survey addresses this gap by being the first to systematically describe and compare organisational aspects across different countries in Europe. It is acknowledged that a limitation of this survey is that the majority of questions were focused on the organisation of inpatient and outpatient PT services; with less of an emphasis on community based PT, private PT clinics or PT departments within long term care. It is possible that the delivery of these services may have differed.

Whilst the high number of participating countries (n?=?23) allows a comprehensive description of the situation across Europe, the relatively low number of centres answering the questionnaire within some countries means that the data should be interpreted with some caution. Nevertheless our response rate (37.3 %) does compare favourably with other online studies [18] where response rates range from 20 to 47 % (mean 33 %). Whilst we attempted to optimise our response rate by ensuring the questionnaire was short (two pages), and considered easy to use (as determined by our extensive piloting phase), a difficulty might have been the language barrier – there was only an English version of the questionnaire. Translation of the questionnaire to national languages might have helped to increase the response rate. An advantage of this on-line survey questionnaire approach is in high data quality due to validation checks (missing, implausible or incomplete answers, elimination of errors in the process of data entry and coding) [19].

There was no official list of workplaces providing PT for patients with MS in individual countries. The identification of candidate centres, together with the person responsible for completing the questionnaire at each centre, was therefore the responsibility of each country representative. These were experienced health professionals (clinicians or clinical researchers) involved in MS physiotherapy for more than 10 years. It is recognised that the identification of, and communication with, centre representatives might have been influenced by personality, professional knowledge and experience, together with the personal motivation and effort of each country and centre representatives. Moreover, the networking system in each country might have also influenced the with-in country response rate, which fluctuated markedly from 6 to 100 % (Table 1). The potential influence of the country representative may therefore have introduced some bias to the results. In future research, other sources should also be used (e.g. National Health Insurance Databases) to systematically identify all centres where people with MS undergo rehabilitation in order to ensure a balanced and representative sample. Whilst these factors should be taken into account in the interpretation of the results, nevertheless this is the first study to provide preliminary information about the organization of PT in MS across Europe.

The results of this survey suggest that European regions are generally similar in key organisational aspects of MS physiotherapy care including the: diversity in size and specialization of workplaces of these services; proportion of MS patients using outpatient compared to inpatient services; availability of individual face-to-face PT; reasons why people with MS are prescribed/referred for PT; and the dosage of inpatient intervention provided. There were, however, some organisational differences across regions, which included the: distribution of professionals within teams; teamwork’s working practice (uni/multi/inter-disciplinary approach); format of the PT sessions (individual, group, autonomous).

There is general agreement that people with complex needs benefit from specialist rehabilitation services [20]. Our results suggest that PT is offered to MS patients in a range of organisations – larger non-specialized hospitals, smaller specialist MS Centres, and specialist MS Rehabilitation Centres. Although the evidence base [21] and professional and patient organisations [21–23] demonstrate a preference for the delivery of services by specialist MS rehabilitation centres, only 38 % of the respondents of this European survey provide such specialist facilities. Recommendations are now in place for rehabilitation to be delivered by coordinated networks in which specialists in neurorehabilitation work within both hospital and community settings to support local generic rehabilitation and care support teams [20, 21].

A positive finding of our survey is that most participating centres reported using a teamwork approach. The role of teamwork in MS has been confirmed in several studies, as documented in a Cochrane review [24]; these however did not distinguish between multidisciplinary and interdisciplinary teamwork approaches. Our results suggest that an interdisciplinary model is slightly more frequently adopted than a multidisciplinary model; with different European regions using different teamwork models. An important research question for the future is the comparative effectiveness of these different approaches.

Our results also suggest differences in the distribution of professionals within teams from across participating centres. This can impact on effective inter-professional working [25]. For example team working can be influenced by the different priorities and roles of different professionals [26] or by the reluctance by some team members to voice opinions [27, 28].

Our survey found differences across countries with regard to who refers/prescribes PT to MS patients and the reasons for its referral/prescription. This is in line with the literature which highlights that, as yet, there remains no universally agreed criteria for patients’ referral for rehabilitation services [29]. Such criteria are an important area for future research. Ideally, patients should be referred for rehabilitation as early as possible [30]. Decision-making processes such as these are influenced by effectiveness, benefit, cost-effectiveness and cost-benefit considerations. Financial, personal, structural and attitudinal factors also influence this [31].

Differences in the types of PT offered by the participating centres were apparent in these survey results. The proportions were calculated with respect to centres offering inpatient/outpatient care. In some countries inpatient rehabilitation prevails, in others outpatient rehabilitation. Whilst individual face-to-face therapy is commonly used across Europe, group therapies and autonomy therapy concept are only used in some European regions. The length and intensity of individual inpatient therapy is broadly similar in different European regions. In contrast, many aspects of group inpatient therapy differ across countries (for example the frequency used, and duration of sessions); mainly being used in the Western region. This is also the case for outpatient therapies, both at an individual and group level. The biggest difference with regard to outpatient therapy is between Western and Eastern Europe: the length of an individual outpatient session is longer, the duration of the program is shorter, and group outpatient treatment does not occur in Eastern countries. The typical dosage of therapy per year, reported by the survey respondents, varies greatly, which is in accordance with the Cochrane review [32]. Contemporary knowledge/research does not yet provide evidence either as to what denotes an optimum ‘dose’ of therapy or the superiority of one therapy over another.