Multiple sclerosis

 The Hospitalization Department

Hospitalization in our neurological rehabilitation department is a special moment in the life of a person with a disability due to multiple sclerosis (MS). In fact, it is the occasion in which different professionals, experts in specific fields, take charge of the different needs that can characterize this disease. Many professional figures are involved such as the neurologist, the physiatrist, the neuroradiologist, the urologist, the gynecologist, the physiotherapists, the neuropsychologists, the occupational therapists, the speech therapists, the nurses, the department coordinators, the neurophysiopathology technicians, the social worker, the nutritionists, the orthopedic technicians, each responsible for taking charge of the patient for their own expertise which means the identification of specific clinical needs and at the same time the implementation of therapeutic, rehabilitative, assistance or diagnostic interventions aimed at strengthening the overall autonomy of the person on a motor, psychological and / or social level. In fact, it is only through the identification of the specific needs of the person, different from individual to individual, that it is possible to develop a rehabilitation path that is as personalized as possible in order to consolidate their autonomy. No less important is obviously the role of the main actor in this process, which is the person with multiple sclerosis who will not undergo these activities as a passive subject but will be encouraged to participate actively and consciously in their own path to strengthen their independence and improve their quality of life.

In practical terms, the department consists of ordinary hospital rooms for adults with one, two or three beds for a total of 30 beds. Hospitalization is necessary either to promote recovery after a disabling attack or following a significant worsening of the disability for patients coming from an acute department or from home. A neurological/physiatric visit will verify the appropriateness of the hospitalization. The admissions office and the ACeSM office can be contacted between 9 am and 16 pm for information. The center operates under an agreement with the national health system and also has rooms for hospitalizations with partial or total payment.

Taking charge of the patient involves a clinical instrumental evaluation aimed at defining the functional and structural deficits, the identification of the motor and cognitive reserve that will allow the definition of the specific rehabilitation therapeutic plan.

During hospitalization, various activities are organized in multi-day sessions that preliminarily include neurological and physiatric evaluation for the clinical classification and identification of rehabilitation and/or therapeutic needs aimed at drafting the individual rehabilitation project (PRI) and managing the specific therapy (disease modifying therapy, DMT) and symptomatic therapy (for example for spasticity, pain, urinary disorders, mood swings, insomnia, etc.) for MS; subsequently, the implementation of the PRI occurs through rehabilitation in the gym or in the room, depending on the needs or clinical conditions, the evaluation and management by the occupational therapist for the identification of any aids, the speech therapy classification (with any related phoniatric evaluations), the preliminary neuropsychological evaluation, management for cognitive stimulation and/or support interviews where required and all the clinical-assistance activities of the case. During the implementation of the PRI, periodic team reassessments take place for any changes to the project during the course of the work. In the absence of contraindications, standard treatments are accompanied by cortical neuromodulation protocols through repetitive magnetic stimulation (rTMS), which has an effect of enhancing rehabilitation activities and which constitutes a cutting-edge method that is well tolerated, consolidated and effective not only for the effect of increasing the persistence of the benefits of physiotherapy but also for a possible greater control of symptoms associated with multiple sclerosis such as fatigue, spasticity and pain.

During hospitalization, in addition to the personalized rehabilitation plan, the patient may also be offered the opportunity to participate in research protocols after informed consent has been obtained. The Center strongly integrates research and assistance, and is equipped with a bio-bank that extends not only to biological fluids, but also to a series of instrumental investigations (neuroimaging, neurophysiological, patient reported outcomes).

The Outpatients Center

The outpatient section of the Center is developed around the neurological clinic, but also benefits from the contribution of all the specialists who work at Casa di Cura Igea (urologist, gynecologist, ophthalmologist, pulmonologist, speech therapist, neuropsychologist, orthopedist, dermatologist, cardiologist, etc.) and all the Services (neuroradiology, neurophysiology in its various branches). The Center's staff consists of five neurologists, a physiatrist and two dedicated professional nurses in addition to the secretarial staff. This multidisciplinary organization, as recommended by the MS Care Unit model, represents the best approach for the patient as it finds in the same location all the skills for profiling his prognosis, for monitoring the effectiveness of the interventions and for dealing with any adverse drug events. The Center also has the possibility of cognitive, physical and integrated outpatient rehabilitation in the Day Hospital. This allows for an intensive rehabilitation hospitalization to be associated with an outpatient maintenance program. A home-based physical and cognitive rehabilitation program is also being developed.

The Center also has an infusion area located in the Via Marcona site for the administration of drugs intravenously.

Outpatient visits and outpatient rehabilitation activities can be carried out with the National Health System. The patient can reach the outpatient clinic either through a visit through the SSN or from the neurorehabilitation department.

At the outpatient appointment, all the tests and visits necessary to define the patient's profile are prescribed and the most appropriate pharmacological therapy is identified and the strategy for any rehabilitation intervention is outlined.

Monitoring of the pharmacological intervention usually includes an initial clinical check-up and some tests after 1 month and 2 months and subsequently regularly every 3 or 6 months.

Nursing staff is available from Monday to Friday from 9.00 to 18.00 at the numbers 02. 4859.3484 or 02.4859.3522

Rehabilitation Program

Multiple sclerosis is a complex and heterogeneous nosological entity, therefore it becomes difficult to draw up a general rehabilitation program, or even impossible to propose a protocol with fixed rules for the rehabilitation of the patient affected by this pathology. Certainly a correct evaluation of the patient in the globality of his difficulties, represents today the starting point to be able to proceed organically to a specific rehabilitation intervention (with the term "globality" we mean, in addition to the clinical aspects of the pathology, also the family, social-work, psychological and environmental aspects that are an integral part of our daily life and of the quality of life in general).

Rehabilitation Treatment

Rehabilitation treatment seeks to limit the functional outcomes of the disease. Preservation of walking (also through the use of: exercises on parallel bars, sticks, Canadians or walkers with or without axillary supports) and the use of residual functions is a priority in these patients. It is necessary to prevent bed rest, the formation of bedsores and joint deformities.

In the acute, spastic phase of the disease, there are problems in the lower limbs and the extensor muscles are more affected. The abductor muscles are more deficient, while the adductors are prevalent. Rehabilitation must benefit the hypotonic muscles and stretching of the hypertonic muscles, subject to spasticity, will be necessary. It will therefore be necessary to:

• Perform a passive kinesis of the ankle joint and subsequent stretching of the Achilles tendon to avoid retractions of the tendon and therefore avoid equinus of the foot. The maneuver must be gradual and slow, with a measured force, to avoid an abnormal reflex.
• Passive mobilization of the hip in abduction and adduction and subsequent lengthening of the adductor muscles of the thigh. Contract-relax and/or hold-relax maneuvers can be associated to obtain further lengthening and acquire some degrees in abduction.
• Passive mobilization of the hip in flexion-extension and subsequent lengthening of the quadriceps muscle and the muscles of the posterior thigh lodge. Here too, pay attention to phenomena of abnormal reflex to stretching.
• Further stretching of the Achilles tendon and quadriceps in the prone position, then with the patient on his stomach, possibly also using contract-relax and/or hodl-relax techniques.

Rehabilitation Concepts

We must not focus only on spasticity or muscle strength, but on the ability to perform a function and its duration; we must enter into the concept of rehabilitation understood as "problem solving", or as a problem solver. It must be functional, rather than just a fight against pathological signs (spasticity, coordination, etc., even if relevant). A pathological sign must become a relevant treatment objective to the extent that it is related to the performance deficit. We must evaluate the potential of the subject and his limits from which we must then take the indication for a useful and possible change. For example, if, when putting on shoes or socks, there is an extension irradiation of the lower limbs or a clonus that in fact prevents me from doing so, we can suggest the opportunity to choose strategies and postures capable of achieving a modification of the basic or district postural tone that serves both as an exercise role and as an expansion of the patient's autonomy. We must try to obtain a change in motor behavior that must become an attitude even after the end of the rehabilitation treatment and not an end to the sterile exercise itself. The therapist must not only be the one who moves but the one who teaches the patient how to use his residual motor resources to obtain an improvement in the quality of life, in personal care, in autonomy and functions.

Observe and evaluate

Of fundamental importance is therefore the observation of the patient and the evaluation of his reactions of straightening and balance, of parachute and protection, from which one can notice the altered and non-physiological motor patterns and on which one can act subsequently. It is also important to work on the rotatory components of the trunk that are also important in intermediate postures. When sitting, the kyphosis attitude already limits the rotations of the trunk, therefore it will be important to modify the starting position of the exercise. Furthermore, good control of balance when sitting already means improving the nursing operations of the family members and improving the thoracic and diaphragmatic dynamics from a respiratory point of view. The exercises to evoke the equilibrium reactions of the pelvis and trunk can also be done on unstable surfaces such as large balls or boards, making the patient sit on them. The patient can also be asked to achieve balances in a crossed manner.

In addition to the evaluation of postural reactions and muscle tone, it is important to evaluate the strength deficit understood as paresis of the aaii (lower limbs). This will involve the patient trying to find strength through fixation and through the use of primitive reflexes such as the symmetrical tonic reflex of the neck to have an anti-gravity effect of "strength" which however determines a loss of selectivity of movement. He tends to fixate himself both visually and by blocking the girdles and the head.

To then Rehabilitate

To work on dysmetria it is advisable to use tactile rather than visual afferents, use small weights to tie to the wrists to exploit the muscular co-contraction with a consequent increase in muscular energy and, finally, break down the movement making it simpler, limiting both the number of components to be controlled simultaneously and the joint excursion. Visual fixation allows to reduce the distortion of vestibular afferents, but when there is nystagmus or pathological movements of the head with oscillations, they make the effectiveness of the artifice and the reference lose.

Since there is a problem of afferents, it will be necessary to work, precisely from the perceptive point of view, both on the superficial sensitivity (tactile and thermal, with discrimination of objects respectively: smooth or rough, hot or cold) and deep sensitivity (e.g. understanding with which finger you are trying to recognize or in what position the limb is located ("proprioception").

In this regard, cognitive exercises are useful (Perfetti method – ETC-) which can also make use of unstable surfaces of different consistency or weight.

Equally useful is also hydrokinesitherapy, both for its “glove effect”, or for its effect from a sensitive-sensorial point of view (since water gives us a tangible sign of contact with it), and for its effect on spasticity. In fact, it has been seen that with exercises in water, both at 10° and at room temperature, good results are obtained. Even cryotherapy often allows the reduction of hypertonia on some patients.

Finally, when positioning yourself in bed, it is good to know that the lateral decubitus position (on your side) is a good solution for partially decompressing the bladder, for dilating the hemithorax that does not support it and for early readaptation to balance.

Even through these small attentions it is possible to intervene on the urological, respiratory and balance aspects, that is, on the vestibular function.

Among the latest developments in both the neurophysiological and rehabilitative fields related to this pathology and not only, not long ago some neurons were discovered (in the F5 area) that have been called “mirror neurons”. It has been seen that these neurons are activated both when the subject performs the action and when he observes another performing it. They are not dependent on the object but on the similar action (e.g. if the monkey learns a sequence in which the action “take the object to put it back in the container” involves the presence of a solid and this is replaced by food, which it had shown to prefer, no significant difference in neuronal activation is found)

The mechanism of mirror neurons is so powerful that these neurons are not activated only when we observe the movement performed by another person. Mirror neurons are also activated when we see on the computer screen a virtual arm that performs the same movement or the schematic image of a human person walking or running

The individual rehabilitation program, placed within the Individual Rehabilitation Project, defines the specific areas of intervention, the immediate and short-term objectives, the operators involved, the times, the methods of delivery and their verification.

The rehabilitation activity benefits from various services:

• Instrumental Therapy Service
• Occupational Therapy Service
• Hydrotherapy Service
• Clinical Phoniatrics and Deglutology Service
• Clinical Neuropsychology Service

The Neuromodulation Center

In our MS Center we apply non-invasive technologies to maximize the effectiveness of physical and cognitive rehabilitation and measure its extent and duration and any changes associated with the course of the disease. Digital technologies, which have proven to be of fundamental importance during the pandemic by allowing us to overcome the barriers imposed by limitations on social contact, are constantly expanding in relation to their extreme usefulness in revealing subtle changes that are not perceptible to the patient or the clinician, or in objectifying and quantifying variations that are perceived but difficult to describe, acting as a "scale" in controlling the "weight" of the nervous system. But while weighing yourself every day, however boring, can be acceptable as a simple and relatively short operation, a daily neurological assessment is difficult to propose. Technological evolution allows us to use sensors or digital applications to evaluate gait, hand motor skills, cognitive functions and, with questionnaires or numerical scales, subjective symptoms such as fatigue, pain, mood swings. It is even possible to acquire some measurements in a “passive” way, that is, without requiring the patient to perform self-assessment tests – for example with a sensor that automatically counts the number of daily steps and evaluates their quality. Our team of researchers is supported by the experience gained through participation in two international studies funded by the European Community – RADAR-CNS (https://www.imi.europa.eu/projects-results/project-factsheets/radar-cns) and Mobilise-D (https://mobilise-d.eu/).

In particular, the RADAR study demonstrated the usefulness of remote monitoring in the early diagnosis of CoViD-19 symptoms and the impact of national and regional restrictions, including lockdown, on the mobility of people with MS. In the Mobilise-D study, which has just ended and whose data are now being analyzed, we are characterizing gait impairment in people with MS and evaluating the possibility of predicting and preventing falls associated with worsening gait. We currently use wearable sensors to monitor gait at home (after careful evaluation in the laboratory with cutting-edge engineering equipment) and web platforms to monitor the speed of reaction to cognitive stimuli. In this regard, in addition to offering the possibility of carrying out cognitive rehabilitation in the department with dedicated digital software, we are conducting a clinical trial aimed at evaluating the effectiveness of a supervised maintenance therapy, carried out at home on a computer independently by the patient, after careful verification of the equipment and adequate training by our operators.

In non-invasive neuromodulation laboratories we have available transcranial magnetic stimulation with H-coil, developed at the National Institutes of Health (USA), which allows us to deliver magnetic fields to larger and deeper brain regions than traditional focal instruments. These stimulations have been shown, in controlled and double-blind clinical studies compared to a placebo (“sham”) therapy, to be effective in improving cognitive functions in subjects affected by dementia (Leocani et al 2020; https://pubmed.ncbi.nlm.nih.gov/33679572/) or motor functions in subjects affected by Parkinson's disease (Leocani et al 2020; https://pubmed.ncbi.nlm.nih.gov/33679570/) and, more recently, in combination with motor neurorehabilitation, in people with progressive MS (Leocani et al AAN 2022; https://www.neurology.org/doi/10.1212/WNL.98.18_supplement.3949).

We are currently studying the evaluation of the efficacy of repetitive magnetic stimulation in improving depressive symptoms and in enhancing the effects of upper limb motor rehabilitation and cognitive rehabilitation.

Finally, we use functional and structural measures of the main neural pathways (visual, auditory, motor, sensory) via evoked potentials and, for the visual system, we combine standard visual evoked potentials (VEPs) with multifocal visual evoked potentials, with state-of-the-art instrumentation that allows to measure the functionality of different sectors of the optic nerve separately, with optical coherence tomography (OCT) that provides images of the retinal neural structures in microscopic detail. Our clinicians have reported the utility of the visual platform in characterizing and monitoring the pattern of demyelination and neurodegeneration in neuroinflammatory demyelinating diseases such as MS and neuromyelitis optica spectrum disorder, both in longitudinal scientific studies and in an international consortium initiative (https://www.imsvisual.org/).

Neurophysiology

Quantifying damage to nerve pathways is a fundamental part of both the diagnosis and monitoring of Multiple Sclerosis. Neurophysiology allows us to measure the electrical activity of nerve fibers, providing information on the quantity and quality of damage:

• Motor evoked potentials (MEP), somatosensory evoked potentials (ESSP), and visual evoked potentials (ffVEP) analyze the level of myelination and the integrity of the related central nervous pathways. With this technique we are able to explore the function, and therefore the integrity and myelination, of neurons within the brain and spinal cord. The test records the electrical activity of these structures following a suitable external stimulus, precisely “evoking” the electrical activity in the nervous system.
• Multifocal visual evoked potentials (mfVEP) represent an evolution of the classic ffPEV technique. This is a new technology currently available in just a few centers in the world! Classic ffPEVs explore the optical pathway as a single pathway, returning a single potential. mfVEPs instead collect information from the optical pathways by segmenting them into 56 sectors and returning as many potentials, thus functioning as a “microscope” on the optical pathway and allowing early or subclinical damage to be seen, which is not visible with ffVEPs.
• Neurography and Electromyography respectively measure the level of myelination and integrity of the neurons constituting the nerve roots and peripheral nerves as well as the electrical activity of the muscular motor units. These techniques are usually used in combination, providing information on the health status of the nerves, the muscle and the neuromuscular junction. In the context of Multiple Sclerosis they are a useful complementary tool to evoked potentials to discriminate damage to the central nervous system from damage to the peripheral nervous system.
• The electroencephalogram (EEG), is also part of the most classical Neurophysiology and allows to record the electrical activity of the cerebral surface. In our facility we analyze the EEG traces by means of an advanced software. This technology allows us to explore the cerebral activity during cognitive tasks, as a useful tool for diagnosis and monitoring of both cognitive decline and the effectiveness of rehabilitation treatment.
• Optical coherence tomography (OCT) has recently been added to these diagnostic techniques. This is a recently developed imaging technique that allows us to analyze the integrity of the retina. The retina is made up of neurons that are part of the central nervous system, allowing us to use the eye as a "window to the brain". By quantifying the health of the retina, we can obtain information on the integrity of the brain, which is useful for both the diagnosis and monitoring of Multiple Sclerosis.

Neuroimaging

The Center uses a 3 Tesla Magnetic Resonance Imaging (MRI) and 2 1.5 Tesla Magnetic Resonance Imaging. All hospitalized patients undergo brain MRI and spinal MRI, in order to evaluate the extent of nerve damage and functional reserve. Thanks to the collaboration with Icometrix, brain volume, white matter and cortical gray matter volume and thalamus volume, total lesion volume, presence and number of new T2 lesions and number of lesions with enhancement after contrast medium are automatically calculated.

The Center collaborates in research programs funded by the European Community (CLAIMS) on the value of resonance markers in monitoring therapies for multiple sclerosis. A research program is active with the Politecnico di Milano for the development and validation of techniques for the analysis of magnetic resonance signals in demyelinating diseases.

The availability of a 64-channel EEG recording system compatible with MRI equipment enables the development of advanced brain connectivity research.

Remote Digital Monitoring

In the MS Center we apply non-invasive technologies to maximize the effectiveness of physical and cognitive rehabilitation and measure its extent and duration and any changes associated with the course of the disease. Digital technologies, which have proven to be of fundamental importance during the pandemic by allowing us to overcome the barriers imposed by limitations on social contact, are continually expanding in relation to their extreme usefulness in revealing subtle changes that are not perceptible to the patient or the clinician, or in objectifying and quantifying variations that are perceived but difficult to describe, acting as a "scale" in controlling the "weight" of the nervous system. But while weighing yourself every day, however boring, can be acceptable as a simple and relatively short operation, a daily neurological assessment is difficult to propose.

Technological evolution allows the use of sensors or digital applications to assess walking, hand motor skills, cognitive functions and, with questionnaires or numerical scales, subjective symptoms such as fatigue, pain, mood swings. It is even possible to acquire some measurements in a “passive” way, that is, without requiring the patient to perform self-assessment tests – for example with a sensor that automatically counts the number of daily steps and evaluates their quality. Our team of researchers is supported by the experience gained through participation in two international studies funded by the European Community – RADAR-CNS (https://www.imi.europa.eu/projects-results/project-factsheets/radar-cns) and Mobilise-D (https://mobilise-d.eu/).

In particular, the RADAR study demonstrated the usefulness of remote monitoring in the early diagnosis of CoViD-19 symptoms and the impact of national and regional restrictions, including lockdown, on the mobility of people with MS. In the Mobilise-D study, which has just ended and whose data are now being analyzed, we are characterizing gait impairment in people with MS and evaluating the possibility of predicting and preventing falls associated with worsening gait. We currently use wearable sensors to monitor gait at home (after careful evaluation in the laboratory with cutting-edge engineering equipment) and web platforms to monitor the speed of reaction to cognitive stimuli. In this regard, in addition to offering the possibility of carrying out cognitive rehabilitation in the department with dedicated digital software, we are conducting a clinical trial aimed at evaluating the effectiveness of a supervised maintenance therapy, carried out at home on a computer independently by the patient, after careful verification of the equipment and adequate training by our operators.

Central Operations Secretariat

The operational secretariat of the Multiple Sclerosis Center acts as a support to both patients and healthcare professionals. It represents the first point of direct contact with the patient and his/her caregivers, assisting them and facilitating their access to care in all phases of the clinical process, diagnosis, treatment, monitoring of the effects of therapies, prompt detection of adverse events.

This function is configured as an essential point of reference not only for patients and their families, but also for doctors, researchers and other healthcare professionals, with the aim of optimising the exchange of information and facilitating communication between the various actors involved in the care process.

The secretariat is open from Monday to Friday from 9:00 to 16:00.

Tel. 02.48593411

e-mail: segreteriacentrosm@casadicuraigea.it