WHAT IS MULTIPLE SCLEROSIS?
Multiple Sclerosis – MS is a chronic disease of the Central Nervous System, involving the brain, spinal cord and optic nerves.
In MS, the immune system is involved in an abnormal inflammatory response that damages myelin, the protective covering of nerve fibres, and, to varying degrees, the nerve fibres themselves.
Because lesions may occur in different areas of the Central Nervous System, the symptoms and course of the disease can vary considerably from one person to another.
MS most commonly affects young and middle-aged adults, although it can develop at other ages.
WHAT PROBLEMS CAN MS CAUSE?
MS can affect many different functions.
Depending on the area of the Central Nervous System involved, symptoms may include:
- muscle weakness,
- spasticity,
- difficulty walking and moving around,
- impaired balance and coordination,
- ataxia or tremor,
- numbness and other sensory disturbances,
- neuropathic or musculoskeletal pain,
- visual disturbances, such as reduced vision due to optic neuritis and/or double vision,
- speech or swallowing difficulties,
- bladder and bowel dysfunction,
- sexual dysfunction.
Fatigue is one of the most common and limiting symptoms of the disease and can significantly affect work, everyday activities and social life.
In some patients, attention, concentration, speed of information processing, memory and other cognitive functions may also be affected.
Anxiety, depression and difficulties in psychological adjustment to a chronic disease may also affect everyday life and quality of life.
HOW DOES MS PROGRESS?
The course of the disease is not the same in every patient.
The traditional terms that continue to be used in clinical practice are:
Relapsing-remitting MS
This is characterised by relapses, meaning the appearance of new neurological symptoms or a significant worsening of existing symptoms, lasting more than 24 hours and not explained by infection, fever, a period of intense stress, exposure to high temperatures or another cause of transient worsening.
Relapses may be followed by a period of partial or complete improvement.
Primary progressive MS
Neurological and functional status gradually deteriorates from the onset of the disease, without the course being characterised mainly by clearly defined relapses and remissions.
Secondary progressive MS
This follows an initial relapsing-remitting course and is subsequently characterised by gradual worsening of neurological function.
We now know that the actual course of MS is often more complex than this simple classification suggests. Relapses and gradual progression may coexist, while some patients may experience progressive deterioration even without obvious relapses.
For this reason, follow-up includes an overall assessment of relapses, changes on MRI and the course of the patient’s neurological and functional status.
WHAT ARE CIS AND RIS?
Clinically Isolated Syndrome (CIS) is a first clinical neurological episode compatible with an inflammatory demyelinating lesion of the Central Nervous System.
Under current diagnostic criteria, MS can be diagnosed in some patients at the time of this first episode if the overall clinical, imaging and laboratory findings fulfil the required criteria. In others, further follow-up is required.
Radiologically Isolated Syndrome (RIS) refers to the incidental finding on MRI of lesions with features suggestive of MS, without a corresponding clinical neurological episode having occurred.
Under the revised 2024 McDonald criteria, some people with RIS may now fulfil the diagnostic criteria for MS even before clinical symptoms develop, when certain additional imaging or laboratory findings are present.
The neurologist assesses the findings and excludes other possible causes.
HOW IS MS DIAGNOSED?
The diagnosis of MS is made by a neurologist and is based on a combination of the medical history, neurological examination, MRI and, when required, additional investigations.
There is no single test that can, on its own, confirm the diagnosis of MS.
MRI of the brain and, when required, the spinal cord is a fundamental part of the diagnostic assessment.
Under the revised 2024 McDonald criteria, the optic nerve is now included among the areas of the Central Nervous System that may contribute to the diagnosis.
In selected cases, examination of the cerebrospinal fluid, Optical Coherence Tomography – OCT, visual evoked potentials and/or other specialised investigations may also be used.
At the same time, it is essential to exclude other conditions that may cause similar symptoms or imaging findings.
HOW IS MS TREATED?
There is currently no cure for MS.
There are, however, many disease-modifying therapies which, depending on the form and characteristics of MS, can reduce relapses and the development of new lesions and limit the risk of long-term deterioration.
The choice of appropriate treatment is made by a specialist neurologist and is individualised according to the course of the disease, relapses, imaging findings, age, coexisting conditions and the needs of each patient.
Significant acute relapses may be treated with corticosteroids when clinically indicated.
A temporary worsening of symptoms does not necessarily mean that a relapse has occurred.
Infections, fever or an increase in body temperature may cause temporary worsening of existing symptoms and require appropriate assessment.
At the same time, symptoms such as spasticity, pain, fatigue, urinary problems, sleep disturbance and mood disorders are also treated.
Medical treatment of the disease and Rehabilitation have different but complementary roles.
WHY IS REHABILITATION IMPORTANT IN MS?
Rehabilitation is an integral part of the overall management of MS.
It does not treat the disease itself and does not replace neurological follow-up or disease-modifying therapy.
It does, however, address the functional consequences of MS and aims to maintain or improve mobility, muscle strength, balance, walking, endurance, the ability to perform activities of daily living, cognitive function and independence.
Regular exercise is a fundamental part of management and may include aerobic exercise, progressive muscle strengthening, flexibility exercises, balance training and motor coordination exercises.
Prevention of secondary complications, such as contractures, pressure ulcers, loss of physical conditioning and the consequences of prolonged immobility, is also particularly important.
HOW DO WE MANAGE MS AT ANAPLASI?
At ANAPLASI, the Multidisciplinary Rehabilitation Team systematically assesses each patient’s neurological, motor, functional, cognitive and psychological status and develops an individualised Rehabilitation programme with specific, measurable therapeutic goals and regular reassessment of the patient’s progress and achievement of those goals.
The programme includes:
- physiotherapy,
- progressive muscle strengthening and endurance exercise,
- balance and gait training,
- specialised aquatic therapy in the Hydrotherapy Pool,
- occupational therapy and training in activities of daily living,
- management of spasticity and pain,
- speech and language therapy for speech and swallowing disorders,
- Clinical Psychology – Neuropsychology, including assessment and, when required, psychological support and cognitive rehabilitation,
- dietetic assessment and follow-up,
- neuro-urological assessment when urinary symptoms are present,
- training in the use of appropriate mobility aids, orthoses and equipment,
- guidance on returning to work and social life,
- assessment and management of sexual dysfunction,
- information, education and guidance for the patient and their family on the course of the disease, the Rehabilitation process and how to manage functional difficulties safely.
For inpatients, respiratory physiotherapy is provided from the time of admission, with the aim of maintaining and improving respiratory function, promoting better lung expansion and facilitating the mobilisation and clearance of bronchial secretions.
WALKING, BALANCE AND PHYSICAL FITNESS
Difficulty walking may result from a combination of muscle weakness, spasticity, sensory impairment, ataxia, balance problems and fatigue.
For this reason, gait training is not the same for every patient.
The programme is adapted to each patient’s specific problems and may include strengthening, endurance exercise, balance and motor coordination training, practice of transfers and walking and, where required, the use of appropriate mobility aids.
Specialised aquatic therapy in the Hydrotherapy Pool may be included in the programme when the patient’s clinical condition and tolerance allow.
MANAGEMENT OF FATIGUE
Fatigue in MS requires systematic assessment because it is not always caused exclusively by the disease itself.
Sleep problems, pain, spasticity, infections, urinary problems, anaemia, thyroid dysfunction, medication, anxiety or depression may make it worse.
In many patients, heat or an increase in body temperature may also temporarily worsen fatigue and other neurological symptoms.
Management may include appropriately adapted exercise, organisation of everyday activities with appropriate rest periods, ergonomic adjustments and treatment of factors that aggravate fatigue.
MANAGEMENT OF SPASTICITY
Spasticity is always assessed in relation to the patient’s functional ability and specific therapeutic goals.
Spasticity is treated when it causes pain, restricts movement or function, interferes with care or contributes to the development of contractures and deformities.
In some patients, spasticity may help maintain posture, standing, walking or transfers. Management should therefore be planned so that these functions are not adversely affected.
Particular attention is required in the management, prevention and avoidance of factors that may aggravate spasticity, such as pressure ulcers, bladder and bowel dysfunction, infections, poor posture or positioning, and pain.
Management may include physiotherapy, appropriate positioning and mobilisation, the use of appropriate aids and orthoses, specialised aquatic therapy in the Hydrotherapy Pool and medication.
In selected patients with focal spasticity, botulinum toxin type A may be injected under electromyographic guidance as part of the overall Rehabilitation programme.
Following the injection, an individualised physiotherapy programme is provided and, where required, occupational therapy. This may include stretching, mobilisation, functional retraining and the use of appropriate aids and orthoses. The Multidisciplinary Team reassesses the outcome against the specific therapeutic goals.
SPEECH AND SWALLOWING
When MS affects speech or swallowing, specialist speech and language therapy assessment and treatment are provided.
At the ANAPLASI Dysphagia Unit, when clinically indicated, Flexible Endoscopic Evaluation of Swallowing (FEES) is performed to assess the safety and efficiency of swallowing and to guide the individualised planning of treatment, feeding and hydration.
CLINICAL PSYCHOLOGY – NEUROPSYCHOLOGY
When cognitive difficulties are present, neuropsychological assessment examines attention, concentration, speed of information processing, memory and other functions that affect everyday life.
Where required, an individualised cognitive rehabilitation programme is developed, with goals related to the real demands of everyday life.
Where clinically indicated, the RehaCom Digital Cognitive Rehabilitation System may be incorporated into the programme, with individualised exercises targeting specific cognitive functions and adjustment of the level of difficulty according to the patient’s abilities and progress.
At the same time, anxiety, depression and difficulties in psychological adjustment to a chronic disease are assessed and treated.
BLADDER AND BOWEL DYSFUNCTION
MS may cause urinary frequency, urgency, nocturia (particularly when the need to pass urine repeatedly interrupts sleep during the night), incontinence or difficulty emptying the bladder completely.
When these problems are present, neuro-urological assessment may include a bladder diary, ultrasound measurement of post-void residual urine and, where clinically indicated, ultrasound assessment of the urinary tract.
Urodynamic testing is not required in every patient with MS. It is performed when there is a specific clinical indication, such as significant or persistent symptoms, difficulty emptying the bladder, increased post-void residual urine, recurrent urinary tract infections or when a more precise assessment of bladder function is required to determine appropriate management.
When present, bowel dysfunction is also assessed and treated, with the aim of regulating bowel function, preventing complications and maintaining the greatest possible degree of independence.
SEXUAL FUNCTION AND REHABILITATION
Sexual dysfunction is common in MS, in both men and women, although it does not affect every patient.
It may involve reduced sexual desire, altered sensation, difficulty achieving orgasm, erectile dysfunction or vaginal dryness. It may be directly related to neurological lesions, but may also be influenced by fatigue, spasticity, pain, bladder dysfunction, psychological factors or certain medications.
When a relevant problem is present and the patient wishes to address it, sexual rehabilitation may include management of symptoms that interfere with sexual activity, practical guidance, counselling and psychological support and, where required, specialist medical treatment in collaboration with the appropriate specialist.
In selected patients, specialist pelvic floor physiotherapy may also be used where clinically indicated.
The aim is to improve sexual function and satisfaction and, where relevant, the couple’s relationship.
The involvement of the patient’s partner may be helpful, if the patient wishes.
ROBOTIC REHABILITATION
In appropriately selected patients with significant motor impairment, robotic rehabilitation systems may be used for controlled and repetitive training in standing and walking and, when there is functional impairment of the upper limb, for retraining of the upper limb and hand.
Robotic technology is used as an adjunct when it serves a specific functional goal and does not replace active therapeutic exercise.
NEUROMODULATION WITH navigated rTMS
Repetitive Transcranial Magnetic Stimulation (rTMS) is being investigated as an adjunctive intervention in MS, mainly for spasticity and, in selected cases, for fatigue or certain motor impairments.
At ANAPLASI, treatment is delivered with neuronavigation – navigated rTMS / Navigated Repetitive Transcranial Magnetic Stimulation – allowing stimulation to be applied accurately to the selected area of the brain.
The method remains adjunctive and under investigation and is not an established treatment for MS itself, nor does it replace disease-modifying therapy or a structured Rehabilitation programme.
CARE OF PATIENTS WITH SEVERE FUNCTIONAL LIMITATION
In patients with very limited mobility, particular attention is given to appropriate positioning, regular changes of position, skin protection and prevention of pressure ulcers and other complications of prolonged immobility.
During Inpatient Rehabilitation at ANAPLASI, advanced therapeutic beds are used for controlled and programmed changes of position, lateral rotation, pressure management, full-chair positioning and, where indicated, gradual progression towards a more upright position.
These functions contribute to both the prevention and management of pressure ulcers.
Percussion and vibration functions may, where clinically indicated, be incorporated into respiratory care.
These functions form part of the overall medical, nursing and therapeutic management and do not replace active mobilisation or a structured Rehabilitation programme.
In patients with a high degree of mobility dependence, electrically powered patient hoists may also be used to support safer transfers from bed to wheelchair and to treatment areas.
REHABILITATION AFTER A RELAPSE
A significant relapse may cause sudden deterioration in mobility, balance, independence in activities of daily living, swallowing or other functions.
Following appropriate neurological treatment, the patient may, when required, undertake an intensive Rehabilitation programme aimed at recovering, to the greatest possible extent, the functions that have been affected and returning as close as possible to the previous level of independence.
HOW IS REHABILITATION PROVIDED?
Rehabilitation may be provided through Inpatient Rehabilitation, Day Rehabilitation or Rehabilitation at Home, according to each patient’s neurological and functional status and individual needs.
WHAT IS THE AIM OF THE REHABILITATION PROGRAMME?
At ANAPLASI, the aim is to enable every patient with MS to maintain and use their functional abilities to the greatest possible extent, achieve the highest possible degree of self-care and independence, and remain active in their personal, family, social and working life.
