New studies reveal high rates of comorbidity and polypharmacy in multiple sclerosis rehabilitation
Two new studies by faculty in the Department of Medicine and University of Toronto PhD candidate Jillian Scandiffio have demonstrated the clinical complexity of patients with multiple sclerosis (MS) in rehabilitation settings. 1, 2 The studies found that patients had a median of three additional health conditions and many were taking multiple medications at once, with about 72.2% meeting the definition of polypharmacy (the use of five or more medications).
“We wanted to explore these concepts because we knew from previous literature that people with MS in Canada experience a range of health inequities and struggle to access the care they need,” says Jillian Scandiffio. “Additionally, the literature has suggested that as people with MS age, they are more likely to have comorbidity and disability, but this has never been systematically documented in a rehabilitation context.”
Previous research in the broader MS population has shown that polypharmacy can contribute to disability. Building on this, Jillian and her supervisor, Dr. Robert Simpson, examined whether polypharmacy was common among patients receiving outpatient rehabilitation through physical medicine & rehabilitation (PM&R) at St. Michael’s Hospital, and whether specific characteristics were associated with it. To do so, they analyzed retrospective chart data from patients referred to the BARLO MS Centre between December 2021 and December 2023, aiming to better understand the clinical characteristics and service needs of this population.
Although neurology, primary care, and PM&R all play important roles in managing complex MS, earlier studies suggest that the division of treatment responsibilities can be unclear, which may lead to challenges in accessing appropriate care. Rehabilitation is specifically recommended in best clinical practice guidelines and focuses on managing symptoms and impairments to minimize disability, optimize function and quality of life, and enhance community participation. Rather than seeking a cure, rehabilitation emphasizes adaptation, considering the patient’s overall function within their environment and personal circumstances.
Comorbidities (the simultaneous presence of two or more medical or psychological conditions) and polypharmacy introduce additional challenges. Comorbid conditions are associated with earlier onset and faster progression of disability, while polypharmacy increases the risk of adverse drug reactions and may worsen fatigue and cognitive difficulties – two of the most common and disabling MS symptoms.
“Our findings suggest that physiatrists working with people with MS should be aware of relevant clinical best practice guidelines for managing multimorbidity and polypharmacy, such as the NICE guidelines, and consider working routinely with a clinical pharmacist who has expertise in MS as part of the specialist multidisciplinary team,” says Dr. Simpson. “We also believe that physiatrists working with people with MS should be trained on a biopsychosocial model of health where they see a person not as a condition but as an individual functioning in a set of personal circumstances unique to them in their given environment. Training physiatrists to understand the complex interaction between multiple symptoms, comorbidities, and polypharmacy in this context can help them provide a holistic overview on treatments that aim to improve quality of life, enhance functioning, and minimize harm.”
The findings also highlight that many symptoms experienced in rehabilitation are “invisible,” such as fatigue, pain, and cognitive or mood-related challenges. As a result, Jillian and Dr. Simpson emphasize the importance of asking patients about these symptoms specifically, and with sensitivity.
“Physiatrists should also be trained to understand common comorbidities in this population and recognize how they should be treated,” says Dr. Simpson.
For example, the most common physical comorbidity identified in the chart review was hypertension, which has been linked to accelerated disability progression. This underscores the need for routine screening and management of such conditions in people with MS. On the mental health side, depression is the most common comorbidity among people with MS accessing physiatry services, highlighting the importance of understanding and applying effective treatments such as psychological therapies and tailored physical activity programming.
In short, physiatrists need to know what comorbidities and symptoms to look for, how to identify them, and how to respond. This includes reviewing a patient’s medication regiment at every visit, applying the Beers Criteria (an evidence-based list of medications that older adults should avoid or use with caution) when appropriate, and collaborating with clinical pharmacists specializing in MS whenever possible.
Dr. Simpson and Jillian hope this new research serves to reassure patients that they’re not alone in managing the complexity of MS.
“Physiatrists have an important leadership role in this regard, coordinating care to address the unique healthcare needs of each individual,” says Jillian. “MS symptoms are notoriously complex and patients should feel comfortable working with their physiatrists to develop a shared understanding for treatment strategy.”
Building on these findings, the team is now developing and implementing clinical best practices for MS rehabilitation across Canada. They are also creating a toolkit to help healthcare providers deliver tailored physical activity recommendations and scaled use of online psychological therapies for people with MS.
Dr. Robert Simpson is supported by The Elizabeth S. Barford City-Wide Research & Education Collaboration Fund in Multiple Sclerosis, which is generously donated by The Ralph M. Barford Foundation.
Jillian Scandiffio is funded by a Canadian Institute for Health Research (CIHR) Doctoral Award for Patient Oriented Research and KITE-Toronto Rehab’s TD Graduate Scholarship.
