Multiple sclerosis (MS) is a chronic disease of the central nervous system that is becoming increasingly prevalent in Spain. Effective management requires a comprehensive, multidisciplinary approach in which neurological nurses play a pivotal role.
ObjectiveTo analyse the clinical and therapeutic progression of MS patients in the province of Ávila between 2013 and 2023, and to consider the implications for nursing practice.
MethodologyA retrospective observational study was conducted on patients diagnosed with MS and registered at the Neurology Clinic of the Ávila Healthcare Complex. Sociodemographic, clinical, and therapeutic variables were analysed for 296 patients, with the approval of the Ethics Committee for Research in Medicine (CEIm) of the Ávila Health Area: GASAV/20243/03.
ResultsThe prevalence increased from 84.47 to 166.5 cases per 100,000 inhabitants over 10 years. The overall mean age at onset was 35 years (±10.96), slightly lower in men (33.70 (±10.78)) than women (35.50 (±11.02)), although this differences was not significant (p = .150). Relapsing remitting MS predominated (67.6%), with no association when related to sex (p = .482). The mean EDSS score was 3.09 (±2.31), though the median fell within a range of 2.5 points. Finally, a significant relationship was found between type of treatment and disability progression with a p < .001 and an effect size of .293. This suggests that the variability in EDSS scores may be due to these factors. The most commonly used treatments were ocrelizumab, cladribine, and natalizumab.
ConclusionsThe number of people in Ávila diagnosed with MS has increased significantly over the last decade, especially among young people. Despite this increase in incidence, the stabilisation of disability suggests more effective clinical management, in which personalised treatment, the use of highly effective disease-modifying treatments and continuous monitoring have played a key role. In this context, nurses play a decisive role in providing support and education, and in improving therapeutic adherence. The results obtained highlight the importance of strengthening these healthcare resources, particularly in less densely populated areas where nurses play an essential role.
La esclerosis múltiple (EM) es una enfermedad crónica del sistema nervioso central, con creciente prevalencia en España. Su manejo requiere un abordaje integral y multidisciplinar, donde la enfermería neurológica tiene un papel clave.
ObjetivoAnalizar la evolución clínica y terapéutica de los pacientes con EM en la provincia de Ávila durante el periodo 2013–2023, y reflexionar sobre las implicaciones para la práctica enfermera.
MetodologíaEstudio observacional retrospectivo de pacientes con diagnóstico de EM registrados en la consulta de Neurología del Complejo Asistencial de Ávila. Se analizaron variables sociodemográficas, clínicas y terapéuticas de 296 pacientes, obteniendo la aprobación del Comité Ético de la Investigación con Medicamentos (CEIm) del Área de Salud de Ávila: GASAV/20243/03.
ResultadosLa prevalencia aumentó de 84,47 a 166,5 casos/100.000 habitantes en 10 años. La edad media de inicio global fue de 35 años (±10,96), siendo en los hombres ligeramente menor (33,70 (±10,78)) que en las mujeres (35,50 (±11,02)), aunque sin diferencias significativas (p = 0,150). Predominó la EM remitente-recurrente (67,6%), sin asociación al relacionarla con el sexo (p = 0,482). La media de EDSS fue de 3,09 (±2,31) aunque la mediana se encontró en un intervalo de 2,5 puntos. Por último, se encontró una relación significativa entre tipo de tratamiento y progresión de discapacidad con un p < 0,001, teniendo un tamaño de efecto de 0,293 lo que sugeriría que la variabilidad de la puntuación de EDSS pudo ser debido a estos. El Ocrelizumab, Cladribina y Natalizumab fueron los tratamientos más utilizados.
ConclusionesLa población abulense con diagnóstico de EM ha experimentado un aumento significativo en la última década, especialmente en jóvenes. A pesar del aumento en la incidencia, la estabilización de la discapacidad sugiere un manejo clínico más eficaz, en el que la personalización del tratamiento, el uso de tratamientos modificadores de la enfermedad de alta eficacia y el seguimiento continuado han desempeñado un pale clave. En este contexto, la enfermería juega un papel determinante en el acompañamiento, la educación y la mejora de la adherencia terapéutica. Los resultados obtenidos invitan a reflexionar sobre la importancia de reforzar estos recursos asistenciales, especialmente en entornos con menor densidad poblacional donde la enfermería tiene un papel esencial.
Multiple sclerosis (MS) is a chronic disease of the central nervous system that predominantly affects young adults, with a higher incidence in women.1 It is characterised by inflammation and the progressive loss of the myelin sheath, which can lead to a wide variety of clinical manifestations and degrees of disability. While the exact aetiology remains unknown, a combination of genetic, immunological, and environmental factors has been identified as determinants in its development.2
In recent years, advances in disease-modifying therapies (DMTs) have significantly improved the control of inflammatory activity and progression of disability, particularly in patients with relapsing-remitting MS. However, therapeutic options for progressive forms remain limited, highlighting the need for research and more effective management strategies.3
The increasing prevalence of MS worldwide has generated a growing demand for specialist care, significantly impacting healthcare resources and patients' quality of life.4 In the United Kingdom, the British Society for Neurology estimates that approximately 55,000 people are affected by this disease, with an estimated incidence of 4.2 new cases per 100,000 inhabitants per year. This highlights the importance of comprehensive and coordinated care to optimise patients' quality of life and functionality.5
From a nursing perspective, nurses play a key role in the care and education of MS patients, facilitating treatment adherence, clinical follow-up, and interdisciplinary coordination.6 Personalised management and early intervention in disease progression can positively impact the progression of disability and patients’ quality of life.7 A recent study highlights the clinical nurse practioner’s essential role in improving early detection and reducing the global burden of the disease.8
Similarly, an observational study conducted by Van Hijfte et al.9 showed that patients with access to specialist MS nursing have a higher level of knowledge about their disease, which has a positive impact on their self-management and therapy adherence.9 Furthermore, education provided by nurses and peer groups has been shown to have positive effects on the quality of life and resilience of MS patients,10 highlighting the need to integrate educational and support strategies into the care of these patients.
In light of this, the present study aims to analyse the clinical and therapeutic progression of MS patients in Ávila province, Castile and León (Spain), which has a dispersed population, and to consider the implications for nursing practice in a context of limited resources.
MethodologyStudy designA retrospective observational study was conducted on the clinical and sociodemographic progression of patients diagnosed with MS in the province of Ávila between 2013 and 2023, inclusive. While the study period was the entire decade, the comparative analysis focused on 2013 and 2023 as representative reference points. This type of design is particularly useful for examining epidemiological trends over time and evaluating the clinical and healthcare impact of the therapeutic strategies implemented, as well as for assessing the implications for nursing practice.
Scope of the studyThe study was conducted in the Neurology Department of the Complejo Asistencial de Ávila, which is a referral centre for the whole of the Castile and León province in Spain. This area has a dispersed, predominantly rural population, providing a relevant perspective on the management of chronic diseases in contexts with geographical and healthcare limitations. A series of selection criteria were established (Table 1).
Study inclusion and exclusion criteria.
| Inclusion criteria: | Exclusion criteria: |
|---|---|
| Patients with a confirmed diagnosis of MS according to the McDonald Criteria11 in force at the time of diagnosis. | Patients with a doubtful diagnosis or atypical clinical progression not compatible with MS. |
| Continuous care at the centre’s Neurology clinic over the period 2013–2023 (inclusive), the patient having attended at least once a year. | |
| Availability of relevant clinical and sociodemographic information (age, sex, MS type, EDSS score,12 MS therapy). | Insufficient clinical data for statistical analysis. |
EDSS: Expanded Disability Status Scale; MS: multiple sclerosis.
The following variables were collected through a review of electronic medical records:
- •
Sociodemographic variables: sex, current age, age at onset of symptoms.
- •
Clinical variables: MS type (relapsing-remitting [RR], secondary progressive [SP], primary progressive [PP]), date of diagnosis, clinical progression measured by Expanded Disability Status Scale (EDSS) score, number of patients who changed clinical phenotype, and time between diagnosis and start of treatment.
- •
Therapeutic variables: initial DMT, treatment changes during follow-up, most recent DMT type, number of treatments used per patient.
The EDSS is a tool widely used in clinical practice and research to assess the degree of neurological disability in people with MS. Developed by Kurtzke in 1983,13 this scale enables the progression of the disease to be quantified over time. Scores range from 0 (no disability) to 10 (death from MS), in increments of .5 points.
The EDSS is based on the assessment of eight neurological functional systems (such as the pyramidal, cerebellar, sensory, and visual systems), as well as an assessment of walking ability based on certain score thresholds. Despite its widespread use, the EDSS has been criticised for its reliance on mobility as the main indicator from intermediate levels onwards, and for having limited sensitivity in detecting subtle changes in the early stages of the disease. Nevertheless, it remains a benchmark scale in clinical studies and therapeutic trials.
The EDSS score was used as the main indicator of disability progression and was recorded in the patient's medical history by the neurology team at each consultation. The criteria of Lublin et al.3 were followed to classify the type of MS.
Statistical analysisThe statistical programme SPSS v.25.0 (licensed by Rovira i Virgili University, IBM) was used for data management and analysis. Descriptive statistics were applied to characterise the sample and describe distributions (mean, median, standard deviation, frequencies and percentages). To compare means, the Student’s t-test was applied for quantitative variables with normal distribution, and the Mann-Whitney U test was applied in cases of non-normality, such as in the comparison of EDSS by sex. The X2 test was used to compare proportions. Analysis of variance (ANOVA) was used to compare EDSS scores according to MS type, and Pearson’s correlation coefficient was used to explore the relationship between quantitative variables (age at onset, EDSS, type of treatment). Finally, a level of statistical significance of p < .05 was established.
Ethical considerationsThis study was conducted in accordance with the ethical principles set out in the Declaration of Helsinki. All data were duly anonymised to ensure patient confidentiality by the IT and Clinical Documentation Service of the Complejo asistencial de Ávila, which provided the data through electronic medical records and those that had already been digitised. Patients were identified by registering those who attended the MS clinic in the province of Ávila between 2013 and 2023. As this was a retrospective study based on pre-existing and anonymised clinical records, informed consent was not required, in accordance with current legislation and following the relevant ethical evaluation.
The research was approved by the Drug Research Ethics Committee (CEIm), with a favourable opinion under code GASAV/20243/03.
ResultSociodemographic characteristicsThe total sample for the study included 296 patients, of whom 66.2% were women and 33.8% were men, with this proportion remaining stable throughout the study period. The mean age of the population increased significantly from 2013 to 2023, from 43.88 years (±11.50) to 48.42 years (±12.32), with a p < .001. Overall, the age at symptom onset was 35 years (±10.96). The results show similar values between the cross-sectional analysis of 2013 and 2023. However, there was a slight increase in age when comparing the ages at onset of patients already diagnosed in 2013 to those in 2023, from 33.66 (±9.57) in 2023 to 34.94 (±10.82). Regarding sex and age at onset, it was found that in 2013 the mean age at onset for men was 30.86 (±9.05), while for women it was 35.30 (±9.54). This trend shows that the age at onset in men will be lower in 2023, at 33.32 years (±10.69) compared to 35.70 years (±10.83).
We sought to analyse whether there was a significant difference between the age at diagnosis and the sex of the patients. In the analysis for 2013, a significant relationship was identified between sex and age at disease onset (p = .010). However, in 2023 there was no significant relationship (p = .094), and neither was the result significant (p = .150) in the overall analysis of the population over the ten-year period (2013–2023). These data do not clarify whether there is a consistent relationship between sex and earlier disease onset.
Evolution of prevalence and incidenceDuring the period 2013–2023, there was a significant increase in the number of people diagnosed with MS in the province of Ávila (p < .000001). In 2013, the prevalence was 84.47 cases per 100,000 inhabitants, while in 2023 this figure had risen to 166.5 cases per 100,000 inhabitants. The cumulative incidence was 5.94 new cases per 100,000 inhabitants per year.
Clinical phenotypes of MSThe most common type of MS was RRMS, accounting for 67.6% of cases. This was followed by secondary progressive MS (SPMS), accounting for 21.3%, and primary progressive MS (PPMS), accounting for 11.1%. Sixteen patients progressed from RRMS to SPMS during follow-up. No statistically significant differences were found between MS type and sex (p = .482) (Table 2).
Relative frequency valuesDegree of disability (EDSS)The mean EDSS score was 3.09 (±2.31) points, with a median of 2.5 and an interquartile range of .9, indicating mild disability in most patients.
No statistically significant differences were identified between sex and overall EDSS scores (p > .05). However, when comparing data from the 2013 cohort with that from the 2023 cohort, significant differences were observed in the progression of disability according to sex (p = .015). In 2013, men had a higher mean score (2.97 ± 2.38) than women (2.58 ± 1.97); but by 2023 this trend had reversed, with a mean of 3.00 (± 2.19) in women compared to 2.71 (± 2.07) in men.
Relationship between disease progression (EDSS) and sociodemographic and clinical variablesPearson's correlation was used to analyse the relationship between EDSS and age at symptom onset. No statistically significant relationship was identified (r = .197; p = .303), although the correlation was weak and positive, suggesting a trend towards greater disability when the disease debuts at older ages (Table 3).
Correlation between EDSS and sex, age at symptom onset, and type of MS.
| Comparison | Main result | p-value | Conclusion |
|---|---|---|---|
| EDSS vs. age at onset | r = .197a | .303 | Not significant; weak positive trend |
| EDSS vs. sex | U = 9828.5b | .852 | Not significant |
| EDSS vs. MS type | F = 20,475c | <.001 | Significant differences between MS types |
r: correlation coefficient.
*p < .05.
EDSS: Expanded Disability Status Scale; MS: multiple sclerosis.
Furthermore, the relationship between EDSS score and sex was examined using the Mann-Whitney U test. No statistically significant differences were found between men and women in terms of disability level (U = 9.828.5; p = .852) (Table 3).
An ANOVA was performed with regard to MS type, revealing a statistically significant relationship between MS type and degree of disability (F = 20.475; p < .001), with higher EDSS scores in the progressive forms of the disease (Table 3).
Comparison between 2013 and 2023When comparing the data from both years, the proportion of MS types remained relatively stable (p = .703). The mean age at onset increased slightly, from 33.66 (±9.473) to 34.94 (±10.82) years (p = .023), and the overall mean age increased significantly (p < .001). The mean EDSS score remained stable, although with differences by sex as described above (Table 4).
Comparison of MS type, sex, and age at disease onset between 2013 and 2023.
| Variables | Year 2013 (n = 145) (%) | Year 2023 (n = 265) (%) | p* |
|---|---|---|---|
| Diagnosis: | .703 | ||
| RRMS | 71.7% | 71.3% | |
| PPMS | 6.2% | 10.2% | |
| SPMS | 22.1% | 18.5% | |
| Sex: | 64.8% | .223 | |
| Female | 35.2% | 67.9% | |
| Male | 32.1% |
| Variables | Year 2013 (n = 145) (Mean ± SD) | Year 2023 (n = 265) (Mean ± SD) | p* |
|---|---|---|---|
| EDSS: | .015 | ||
| Female | 2.58 (±1.97) | 3.00 (±2.19) | |
| Male | 2.97 (±2.38) | 2.71 (±2.07) | |
| Age at onset: | 35.70 (±10.83) | .1503 | |
| Female | 35.20 (±9.55) | 33.32 (±10.70) | |
| Male | 30.86 (±9.05) | ||
| Age at onset (years) | 33.66 (±9.57) | 34.94 (±10.83) | .023 |
| Population age (years) | 43.88 (±11.51) | 48.42 (±12.33) | <.001 |
| EDSS (score) | 2.72 (±2.12) | 2.90 (±2.90) | .312 |
SD: standard deviation.
A total of 19 types of DMT were used during the analysed period. Highly effective disease-modifying treatments (HEDMTs) predominated, with ocrelizumab, cladribine, and natalizumab being the most commonly used. Ocrelizumab was particularly common in SPMS, while cladribine and natalizumab were primarily used in RRMS.
The overall analysis showed a significant relationship between therapy type and EDSS score (p < .001), suggesting that disability progression may be influenced by the therapy received.
In the sub-analysis of patients treated between 2018 and 2023, interferon beta-1a was the most commonly used initial treatment (18.8%), followed by cladribine (17.2%) and natalizumab (14.1%). An association was found between the type of MS and the initial DMT (p = .008), as well as a relationship between age at symptom onset and therapy type (p = .02), indicating that different therapeutic decisions are made depending on the patient's profile. The low representation of the ‘intermediate therapy’ category in the cohort analysed reflects the fact that, in clinical practice of recent years, patients tend to maintain their initial therapy or make a single change to a more effective drug, undergoing intermediate therapeutic phases. This could be linked to the more widespread use of early intensive therapy strategies (Table 5).
Description of therapies from diagnosis to 2023, divided into three stages and represented by absolute frequencies and percentages.
| Therapy | First therapya | Intermediate therapyb | Final therapyc |
|---|---|---|---|
| Interferon beta-1a | 12 (18.8%) | – | 1 (1.6%) |
| Glatiramer acetate | 2 (3.1%) | – | – |
| Fingolimod | 2 (3.1%) | 1 (1.6%) | 1 (1.6%) |
| Siponimod | 4 (6.3%) | – | 2 (3.1%) |
| Teriflunamide | 1 (1.6%) | – | 1 (1.6%) |
| Ocrelizumab | 7 (10.9%) | – | 10 (15.6%) |
| Rituximab | 1 (1.6%) | – | 1 (1.6%) |
| Cladribine | 11 (17.2%) | – | 19 (29.7%) |
| Natalizumab | 9 (14.1%) | – | 14 (21.9%) |
| Dimethyl fumarate | 7 (10.9%) | – | 1 (1.6%) |
| Ozanimod | 1 (1.6%) | – | 2 (3.1%) |
| Pegylated interferon beta-1a | 2 (3.1%) | – | – |
| Alentezumab | – | – | 1 (1.6%) |
| Ofatumumab | – | – | 4 (6.3%) |
| Ponesimod | – | – | 1 (1.6%) |
| Diroximel fumarate | – | 1 (1.6%) | 3 (4.7%) |
| No therapyd | 5 (7.8%) | – | 3 (4.7%) |
This study has enabled us to analyse the clinical and therapeutic progression of MS patients in the province of Ávila, in the autonomous community of Castile and León (Spain), over the decade from 2013 to 2023. Compared with national studies, such as those conducted by García-Estévez et al.13 and Perez-Carmona et al.,4 it is evident that the prevalence of MS in Spain has risen to between 80 and 100 cases per 100,000 inhabitants. This trend is consistent with the data obtained in this study, which recorded a prevalence of 166.5 cases per 100,000 inhabitants. In addition to this increase in prevalence, the incidence is also higher when compared to populations similar to that of Ávila. Juanatey et al.14 conducted a study in Zamora, which recorded a prevalence of 98 cases per 100,000 inhabitants and a lower incidence of 3.5 new cases per 100,000 inhabitants/year, compared to 5.94 new cases per 100,000 inhabitants/year in Ávila. These data reinforce findings of a sustained increase in both the prevalence and incidence of MS in our population. Furthermore, the increase in prevalence in Ávila, which has practically doubled in a decade, coincides with the national adjusted growth data, estimated at approximately +26.6 cases per 100,000 inhabitants every 10 years.4,5,13 This increase could be due to a combination of factors such as changes in diagnostic criteria, improvements in diagnostic techniques, earlier access to neurological care, and longer survival times resulting from more effective DMTs.1,2
The age at onset of initial symptoms was very similar to the national average, at 32.1 compared to 34.94 (±10.82) for the province. Similarly, the age at onset of symptoms over the 10 years studied in the Ávila population remained stable, with the median remaining at 35. These figures coincide with those of several studies conducted in other areas of the country, where the average age at onset was 31.10 (±7.99) in the case of Bellvitge Hospital and 33.98 (±10.95) in the region of Asturias. This reinforces the stability of this variable in different regions of Spain.15,16
Despite the progressive ageing of the cohort, as reflected by the significant increase in the average age of patients in 2023, there was no corresponding increase in disability. This remained at a mean of 2.50 points over the last 10 years, indicating a population with mild to moderate disability. While there was a relationship between age and cumulative disability in 2013, this disappeared by 2023. This stability, as well as the disappearance of the relationship between this value and age, suggests better control of inflammatory activity and the early introduction of highly effective DMT. This corresponds chronologically with the emergence of new therapeutic lines.3,6,17,18 This finding coincides with recent studies which have shown that patients who start treatment in the early stages and maintain structured clinical follow-up have less long-term disability accumulation.2,7 In this regard, implementing care models based on risk stratification and a multidisciplinary approach has been crucial in containing the progression of the disease.6,19
Longitudinal analysis revealed a change in the progression of disability according to sex. While men had higher levels of disability (2.97 vs. 2.58) in 2013, in 2023 it was women who had a higher mean EDSS score (3.00 vs. 2.71). This reversal could be influenced by biological or social differences, as well as cohort-specific factors, such as differences in exposure to and response to disease-modifying treatments, the distribution of clinical phenotypes (RR vs. progressive) or therapeutic adherence.20,21
Similarly, the influence of hormonal factors on progression independent of relapse activity (PIRA) has been described in women. Specifically, the early use of oral contraceptives has been associated with a lower risk of progression, whereas menopause or a history of pregnancy at the time of diagnosis was associated with an increased risk.22
Taken together, these findings indicate that hormonal, clinical, and therapy factors may explain the differences observed between sexes at different stages of the disease. While the overall differences in our analysis did not reach statistical significance, the findings highlight the need to incorporate a sex perspective in the assessment and follow-up of patients with MS.
With regard to MS type, age at onset, and degree of disability, there was a statistically significant relationship between MS type and EDSS score, confirming that progressive phenotypes are associated with greater disability. However, although no strong correlation was found between age at onset and EDSS score, a trend was identified suggesting that late-onset patients may have a worse outcome, as reported in the literature.1,23
Analysis of the therapy regimen showed a predominance of highly effective therapies, such as ocrelizumab, cladribine, and natalizumab, which is in line with current recommendations for patients with high inflammatory activity.6,24 Additionally, a significant association was found between therapy type and EDSS score, reinforcing the hypothesis that an appropriate therapeutic choice can positively impact clinical progression.3,10 When choosing therapy, sex does not seem to influence the choice of therapy, suggesting that other factors may be more decisive in this decision. One such factor is the age at symptom onset, as this could provide an indication of disease duration. This variable, combined with the year of diagnosis, offers a more complete perspective on the progression of MS.
Therapy adherence is therefore a key element in controlling the disease. A recent study in Spain found an average adherence rate of 87.5%. The main factors associated with non-adherence were cognitive impairment and alcohol or drug use. This highlights the importance of oral therapies in promoting adherence.25
It is in this scenario that the involvement of nurses in clinical practice plays an essential role. Their training in advanced pharmacology, monitoring of adverse effects, and in patient education on the correct administration and monitoring of DMTs enables greater adherence and, with it, a decrease in disease progression.5,24 Specialist MS nursing intervention has been shown to be effective in improving therapeutic adherence, reducing hospital admissions, and increasing patient satisfaction.9,26
While the present study did not include variables related to therapeutic adherence or nursing intervention, it is important to note that the literature highlights the potential of structured, multidisciplinary clinical follow-up to optimise therapy outcomes.6,8
In this regard, care models involving specialist nursing could contribute to improving clinical control of patients, particularly in contexts with limited resources such as the province of Ávila.19,26,27
Finally, this reflection on the implications for nursing practice in a context with limited resources proposes a model that could be replicated in other provinces with similar characteristics, highlighting the potential of specialist nursing as the foundation of comprehensive care in MS.
LimitationsThis study has a number of limitations that are inherent to its retrospective design. As it is based on a review of medical records, the quality and accuracy of the data depend on the availability of records, which may have impacted the accuracy of some variables. Furthermore, although widely used, the EDSS score may vary between evaluators and has limited sensitivity for detecting subtle changes in the early stages of the disease.
Another relevant limitation is the absence of psychosocial, functional, and quality-of-life variables, which would have provided a more comprehensive view of the disease’s impact and the role of nursing in areas such as therapy adherence, self-management, and emotional support. Similarly, the statistical analysis did not include adjustments for potential confounding factors, such as disease duration, which could weaken the internal validity of some of the associations observed.
Geographical representativeness must also be considered. While the study covers all MS patients treated at a provincial referral centre, the population of Ávila is characterised by its dispersion and ageing. This could limit the generalisation of the results, although it could be compared with other areas that have similar sociodemographic characteristics.
ConclusionsOver the last decade, the prevalence of MS has increased in the province of Ávila, in line with national and international trends. The disease primarily affects young working-age women, which has a significant social and health impact.
However, despite this increase, the progression of disability has remained stable, suggesting that highly effective disease-modifying therapies such as ocrelizumab and natalizumab, together with an early and personalised clinical approach, have helped to slow the functional deterioration of patients.
In this context, neurological nursing is proving to be a fundamental pillar in the comprehensive management of MS, particularly with regard to health education, therapeutic adherence, and emotional support.
Furthermore, geographical dispersion and sex-related differences in disability progression highlight the importance of a nursing approach sensitive to each patient's context and profile, combining face-to-face and remote care models to ensure equitable access to care.
In conclusion, this study reinforces the importance of specialist MS nursing and patient-centred care models in settings with limited resources, as these are key to improving quality of life and optimising long-term clinical outcomes for those affected.
FundingNo funding was required for this study.
The authors have no conflict of interests to declare.
