# Physiotherapy in Multiple Sclerosis - Savonia AMK

> Multiple sclerosis (MS) is the most common progressive, inflammatory, demyelinating disease usually diagnosed between 20-40 years of age, in which the myelin sheath of nerve cells in the brain and spinal cord is damaged.

## Blended Intensive Program in Neurological Rehabilitation
In 20 – 25. 2 . 2023, a Blended Intensive program in Neurological rehabilitation was held. More than 30 physiotherapy students and teachers from three universities (Savonia University of Applied Sciences, Finland; Third Faculty of Medicine, Charles University, Czech Republic; and University of Thessaly, Greece) actively participated. Students worked together and wrote articles devoted to the following themes: stroke and rehabilitation, multiple sclerosis and rehabilitation, Parkinson’s disease and rehabilitation, children with neurological disorders and rehabilitation, spinal cord injury and rehabilitation, and virtual reality and exergames in rehabilitation of neurological patients.

## Understanding Multiple Sclerosis
Multiple sclerosis (MS) is the most common progressive, inflammatory, demyelinating disease usually diagnosed between 20-40 years of age, in which the myelin sheath of nerve cells in the brain and spinal cord is damaged. This damage decreases the transmitting ability of neurons, resulting in a wide range of symptoms including physical, mental, and cognitive problems. 

MS takes different forms based on the way that the symptoms may occur:
* **Relapse-remitting MS:** Symptoms occur in isolated attacks.
* **Progressive forms of MS:** Symptoms build up over time.

The most common symptoms include vision problems, muscle weakness, fatigue, spasticity, balance and gait issues, cognitive-mental fatigue, and depression. Females are affected more frequently than males. Pathogenesis may involve genetic susceptibility, infectious factors, and environmental factors. Diagnosis is confirmed by clinical estimation, Magnetic Resonance Imaging (MRI), lumbar puncture, and evoked potential tests.

## Treatment Approaches
There is a variety of treatments that can control relapses and delay long-term functional disability. Patients follow medical guidelines involving medication, physical therapy, and psychological therapy. Physical therapy can occur in various environments (water, indoor, or outdoor) and utilizes hands-on methods like the Bobath concept or Proprioceptive Neuromuscular Facilitation (PNF), as well as innovative technologies.

## Physiotherapy in the Czech Republic
Physiotherapy in the Czech Republic is based on two pillars:
1. **Neurodevelopmental techniques:** Inspired by child motor development, these methods stimulate the central nervous system to activate inborn motor programs to boost neuroplasticity and correct pathological posture. Common methods include the Proprioceptive Neuromuscular Facilitation (Kabat method), Reflex locomotion by Vojta, Dynamic Neuromuscular Stabilization by Kolář, Bobath concept, Sensorimotor stimulation, and Motor Programmes Activating Therapy by Řasová.
2. **Muscle re-education:** Involves strengthening exercises (engaging whole muscle chains) and aerobic exercises using equipment like RedCord, resistance bands, gymnastic balls, and unstable platforms. Stretching and soft tissue techniques are also utilized.

## Physiotherapy in Greece
In Greece, management includes:
* **Stretching and resistance exercise:** To manage rigidity, stiffness, and muscle weakness.
* **Alternative methods:** Aquatic therapy, virtual reality, mHealth apps, equine therapy, and green exercise are used to increase patient motivation.
* **Aquatic therapy:** Helps increase vascular and lung capacity, muscle strength, and balance while reducing fatigue and pain.
* **Functional therapy:** Neurodevelopmental techniques like PNF, Dynamic Neuromuscular Stabilization, and the Bobath concept are used for task-oriented activities.

## Observations from Finland
During the stay in Finland, it was observed that physiotherapists frequently utilize modern rehabilitation technologies, such as grounded exoskeletons (e.g., Lokomat), treadmill exercises, and virtual reality. Additionally, "NeuroDance" is used as a method for rehabilitation, socialization, and self-expression. Hands-on methods appear to be less widely used in Finland compared to the Czech Republic and Greece.

## Conclusion
The biggest similarity between the Czech Republic and Greece is the heavy reliance on hands-on techniques. In contrast, Finland primarily utilizes a broad spectrum of available technologies. A minor difference between the Czech Republic and Greece is that the Czech Republic prioritizes neurodevelopmental methods, while Greece places greater emphasis on aquatic and green therapy.

## Authors
* **Petra Chmelíková**, physiotherapy student, Charles University, Third Faculty of Medicine, Czech Republic
* **Athanasia Kanellopoulou**, physiotherapy student, University of Thessaly, Greece
* **Michaela Raková**, physiotherapy student, Charles University, Third Faculty of Medicine, Czech Republic
* **Dr. Marja Äijö**, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Kuopio, Finland
* **Dr. Kamila Řasová**, Ph.D., Associative professor of Physiotherapy, Third Faculty of Medicine, Charles University, Czech Republic
* **Dr. Thomas Besios**, Assistant Professor, Department School of Health Sciences, University of Thessaly, Greece

## References
* Kargarfard M, Shariat A, Ingle L, Cleland JA & Kargarfard M. 2018. Randomized Controlled Trial to Examine the Impact of Aquatic Exercise Training on Functional Capacity, Balance, and Perceptions of Fatigue in Female Patients With Multiple Sclerosis. Arch Phys Med Rehabil. 99(2):234-241. doi: 10.1016/j.apmr.2017.06.015.
* Multiple Sclerosis. ad. Read: 23.2.2023. [https://www.ninds.nih.gov/health-information/disorders/multiple-sclerosis](https://www.ninds.nih.gov/health-information/disorders/multiple-sclerosis)
* Äijö M, Řasová K & Besios T. 2022. Neurological rehabilitation, Blended Intensive program has started. Savonia Article, Savonia-ammattikorkeakoulu. [https://www.savonia.fi/en/articles/savonia-article-neurological-rehabilitation-blended-intensive-program-has-started/](https://www.savonia.fi/en/articles/savonia-article-neurological-rehabilitation-blended-intensive-program-has-started/)