An Analysis of Multiple Sclerosis Treatment Using the PICO Framework

Introduction

Multiple sclerosis (MS) is a neurological disease that results in a range of debilitating symptoms, such as difficulty controlling muscles, spasms, problem speaking, and emotional difficulties.  The precise causes of MS are not fully understood, although environmental, genetic, and bacterial influences may all play a role in the development of this disease. As the causes are not always the same, theoretical and clinical approaches to nursing care for MS patients tends to differ greatly as well. The purpose of this paper is to present an analysis of MS theory and care using the population, intervention, comparison, and outcomes (PICO) approach. This approach emphasizes a systematic exploration of a relevant clinical question in order to promote more evidence-based care. The PICO variables are first described, followed by an analysis of literature related to the proposed treatment type. Contributing theories are outlined, based on the relationship between the PICO variables.  An appraisal of these findings will then be presented based on the literature, followed by a discussion as to the potential efficacy of this treatment. This paper will conclude with a brief summary and outline of key points.  

PICO Variables:

P: The population at hand includes patients currently diagnosed with multiple sclerosis and receiving treatment at Texas Neurology, Dallas, Texas.

I: The independent variable in this analysis involves the establishment of a formal, structured, reproducible education curriculum within The Multiple Sclerosis Center of Excellence, which will include pathophysiology, symptoms expectations, treatment, and prognosis. The antecedent variable includes previous nurse education regarding pathophysiology of MS, and patient's familiarity with disease process education. The extraneous variable is the nurse's ability to teach at patient's level of understanding, willingness of the patient to participate in learning activities, family support and patient cognition. The moderator variable is a lack of patient participation. 

C: Currently, there is no structured program within this location. 

O: The dependent variable is the enhancement in knowledge in patients regarding the disease processes of MS, and increased confidence related to self-care activities following intervention. 

Review of Literature

The problem at hand is that of MS, a disease characterized by a structural damage to the central nervous system (CNS). Specifically, MS occurs as a result of damage to the surrounding layers of nerve cells within the brain, spinal cord, and optic nerves (Polman et al., 2011). Specifically, this paper relates to MS patients currently diagnosed with MS and receiving treatment at Texas Neurology, a neurology clinic located in Dallas, Texas. MS results in multiple physical, emotional, and behavioral difficulties. Among the most frequent signs and symptoms of MS are visual and sensory difficulties due to damage to cells within the optic nerve (Polman et al., 2011). The main problems within the CNS include chronic fatigue, cognitive dysfunction, and other mood disorders (Ben-Zacharia, 2011). Musculoskeletal problems include general muscular weakness, spasms, and a lack of muscular coordination (Ben-Zacharia, 2011). MS also results on sensory dysfunctions, such as chronic pain, paresthesia (a pervading tickling or burning feeling), hypothesia (reduced sensitivity to all forms of sensory stimuli), bowel and urinary dysfunctions, and visual and speech dysfunctions (Ben-Zacharia, 2011). 

Relationship between Independent and Dependent Variables

In the current PICO scenario, the independent variable, or "I", is the establishment of a formal, structured, reproducible educational curriculum within The Multiple Sclerosis Center of Excellence, which will include pathophysiology, symptoms expectations, treatment, and prognosis. Recent research has lent considerable support to the role of informed decision-making in the treatment of MS. According to Coulter, Entwistle, and Gilbert (1999), the delivery unbiased information is effective in preventing patients from forming unrealistic expectations about the course of their MS, as well as the effects of therapies. The development of such expectations can result in negative psychological outcomes and detract from medical care (Ferrie, Dunlop, & Bianchard, 2010). Furthermore, Kasper, Kopke, Muhlhauser, and found that the presentation of balanced and relevant information related to MS care allowed patients more autonomy in their decisions, as well as more collaborative decision-making with physicians. This seemingly paradoxical result likely demonstrates the multiple beneficial effects of involving patients in decision-making, and the positive outcomes that can occur from both patients and medical staff. According to Kasper and colleagues (2006), the provision of timely and relevant information related to MS treatment can not only directly impact patients' knowledge, but also positively influence psychological outcomes such as quality of life and perceptions of control (Kasper et al., 2006). These psychological outcomes may increase the utilization of health services and lead to more efficacious population-wide MS treatment (Kasper et al., 2006). 

Potential Antecedent Variables for the PICO

The antecedent variables in the current case include previous nurse education regarding pathophysiology of MS and the patient's prior familiarity with disease education through learning about their health history. Research has shown that each of these variables can have a considerable impact on the intervention outcome.  A failure to account for these variables can also lead to misinformation regarding treatment outcomes, and poort patient-centered care. For example, a significant problem that exists regarding MS is the complexity of various treatment options that sometimes result in unrealistic expectations and adverse intervention consequences (Ferrier et al., 2010). As treatment options continue to increase in their complexity, patients are more prone to misinformation about treatment outcomes and their potential psychological, physical, and behavioral side effects (Ferrier et al., 2010). Therefore, greater research is needed to explore the role of differing educational programs in informing MS patients of their treatment options. Previous nurse education regarding the pathophysiology of MS, as well as the patient's familiarity with disease process education, can have a tremendous impact on the outcome of any educational intervention. 

Potential Moderator Variables for the PICO

The moderator variable in the current case pertains to a potential lack of patient participation. Heesen and colleagues (2007) demonstrated that allowing patients to be involved in the decision-making process may result in more successful adherence to treatment and provide economic benefits to hospitals and care facilities. The combination of more evidence-based decision-making and the psychological benefits of increased autonomy may result in positive effects on the MS disease course (Heesen et al., 2007). Heesen and colleagues (2007) contend that this positive impact on physical MS outcomes may be due to more efficacious disease management strategies stemming from patient-led decision-making. Therefore, encouraging participants to actively engage in the educational intervention is critical to the program's success. 

Potential Extraneous Variable for the PICO

The extraneous variables in this case include the nurse's ability to teach at the patient's level of understanding, his or her willingness to learn or engage in the activities, family support, and patient cognition. Kopke, Kasper, Muhlhauser, Nubling and Heesen's (2009) investigation into the role of informed decision-making in relapse prevention wass among the first to objectively consider the impact of the impact of nurse education on patient autonomy, and how this autonomy impacted patient's understanding. Drawing on a true randomized design, these researchers discovered that nurses who promoted greater autonomy and were more skilled at delivering information to patients were able to generate greater participation in decision-making than those who were simply provided with a standardized information leaflet given to all MS patients within the facility. Results from this study demonstrated that a four-hour educational intervention emphasizing effective nursing pedagogical methods was associated with substantially improved autonomy related to treatment decisions, as well as improved quality of life, reduced disability status, and reduced adverse effects resulting from corticosteroid therapies (Kopke et al., 2009). Though these physical effects were less prominent, this study illustrates the multiple benefits of promoting more informed decision-making for patients with MS. 

Relationship between the Variables

Each of the above PICO variables appears to work in an interrelated manner that ultimately impacts an educational intervention's effectiveness. Previous research has illustrated how multiple factors within an intervention (e.g., nurse knowledge, patient autonomy, patient participation, and symptoms expectations) can influence the outcomes of MS disease processes. For example, Heesen, Solari, Giordano, Kasper, and Kopke (2011) reflected on the role informed decision-making can play in mediating the challenges associated with increasingly complex therapeutic options for MS. According to these authors, advancements have been made in the effectiveness and ease of new pharmacological treatments, although the side effects may be much more severe (Heesen et al., 2011). As a result, educational interventions to provide information in these negative side effects can greatly improve treatment outcomes on multiple levels. More natural treatments are also being explored such as the use of CBD oil. Heesen and colleagues (2011) provide numerous examples in literature as to how such interventions can increase patient knowledge and management of MS care. Among these examples are the contributing roles these aforementioned independent, dependent, antecedent, extraneous, and moderator variables play in educational outcomes. Ultimately, these authors recommend the development of modular programs that can be administered within MS care facilities, accounting for each of these variables, that provide current and accurate information that empowers patients to continue to make the most informed decisions regarding their care (Heesen et al., 2011).

(Table 1 omitted for preview. Available via download)

Schematic Model of PICO Variables

(Model omitted for preview. Available via download)

Theories Potentially Serving as Framework for Current PICO Project

A range of theories may potentially serve as the framework for the current PICO project. Newman's Theory of Becoming, which states that all beings are interconnected and part of a universal consciousness, may be helpful for understanding the manner in which the nurse, patient, family, and all other involved parties may interact to produce a positive intervention outcome (Cody, 2006). Pope's Middle Range Theory may be effective in connecting the borad insights of more broad theories (e.g., Newman's Theory of Becoming), with specific practice-related concepts related to the intervention at hand, such as the necessity to promote resilience on the part of the patient (Cody, 2006). Stanford's theory of providing care through relation and dialogue emphasizes the role effective communication provides in determining treatment outcomes, whereas Murdaugh's Theory of Self-Care Management for Vulnerable Populations illustrates methods for promoting greater patient autonomy when working with patients who lack certain resources to care for themselves. Regardless of the specific theory adopted, it is critical that any educational intervention rely on theory in order to promote a consistent and coherent framework from which specific hypotheses can be tested and measured (Kenny, 2006).

Conclusion

The purpose of this paper was to present a PICO analysis of MS treatment and theory. Specifically, this paper explored the impact of educational interventions on MS care in order to lend support to a reproducible educational curriculum for patients within a particular care facility in Dallas, Texas. Recent research was reviewed and appraised in order to evaluate the potential impact of such an intervention. Based on the evidence presented in this analysis, it is clear that such educational interventions can offer a range of physical, psychological, and behavioral outcomes for MS patients. The increased autonomy associated with treatment education has been demonstrated to improve treatment adherence and MS relapse conditions. Additionally, informing patients of the potential effects of varying treatment decisions can help patients form realistic expectations for MS care and reduce psychological stress during MS interventions. Finally, evidence suggests that involving patients in treatment decisions can improve collaboration with physicians, leading to more needs based and efficacious care. Future research is needed in order to more fully understand the benefits of educational interventions in MS care, as well as the most effective program contents. 

References

Ben-Zacharia, A. (2011). Therapeutics for multiple sclerosis symptoms. Mount Sinai Journal of Medicine, 78(2), 176-191.

Cody, W. (Ed.) (2006). Philosophical and theoretical perspectives for advanced nursing practice. Sudbury, MA: Jones & Bartlett Publishers. 

Coulter, A., Entwistle, V., & Gilbert, D. (1999). Sharing decisions with patients: Is the information good enough? British Medical Journal, 318, 318-322.

Ferrier, S., Dunlop, N., & Blanchard, C. (2010). The role of outcome expectations and self- efficacy in explaining physical activity behaviors of individuals with multiple sclerosis. Behavioral Medicine, 36(1), 7-11. 

Heesen, C., Kasper, J., Kopke, S., Richter, T., Segal, J., & Muhlhauser, I. (2007). Informed shared decision making in multiple sclerosis - inevitable or impossible? Journal of the Neurological Sciences, 259, 109-117.

Heesen, C., Solari, A., Giordano, A., Kasper, J., & Kopke, S. (2011). Decisions on multiple sclerosis immunotherapy: New treatment complexities urge patient engagement. Journal of the Neurological Sciences, 306(1-2), 192-197. 

Kasper, J., Kopke, S., Muhlhauser, I., & Heesen, C. (1999). Evidence-based patient information about treatment of multiple sclerosis. A phase one study on comprehension and emotional responses. Patient Education and Counseling, 62, 56-63.

Kenny, J. W. (2006). Theory-based advanced nursing practice. In W. Cody (Ed.), Philosophical and Theoretical Perspectives for Advanced Nursing Practice (pp. 295-310). Sudbury, MA: Jones & Bartlett Publishers. 

Kopke, S., Kasper, J., Muhlhauser, I., Nubling, M, & Heesen, C. (2009). Patient education program to enhance decision autonomy in multiple sclerosis relapse management: A randomized controlled trial. Multiple Sclerosis Journal, 15(1), 96-104.

Polman, C. H., Reingold, S. C., Banwell, B., Clanet, M., Cohen, J. A., Filippi, M., ... (2011). diagnostic criteria for multiple sclerosis: 2010 revisions to McDonald criteria. Annals of Neurology, 69(2), 292-302.