INVITATION 13th SIG MOBILITY
"Content of physical rehabilitation in multiple sclerosis"
Prague, Czech Republic
Dear RIMS member,
Dear Collegue with interest in MS Mobility issues,
It is our pleasure to meet you in the 13th SIG MOBILITY meeting in Prague.
You are welcome on satellite meetings with workgroup members and interested
people will take place on Thursday May 20th, and with full day programs on
Friday and Saturday.
PhDr. Kamila Řasová, Ph.D. Organizer
Peter Feys (PhD, PT) Chairman SIG Mobility,
Paul Van Asch (PT) Co-chair SIG Mobility
Information for presenters in CLINICAL SESSION who will present different
therapeutic concepts in physical therapy for MS in Europe
Two patients will be present for practical part.
PACIENT 1: Men, 41 years old, Multiple Sclerosis, relaps - remittent form,
diagnosis from 2002, EDSS: 5, treated by immunomodulatory drug - Betaferon
from 09/09. Hemiparesis sinistra, paraparesis, ataxie, hemihypestesie.
Videos are provided at:
<http://www.youtube.com/watch?v=243_IL11csM>
http://www.youtube.com/watch?v=243_IL11csM
<http://www.youtube.com/watch?v=6fX57egY2Vk>
http://www.youtube.com/watch?v=6fX57egY2Vk
<http://www.youtube.com/watch?v=iqTK-cKulcg>
http://www.youtube.com/watch?v=iqTK-cKulcg
PACIENT 2: Men, 43 years old, Multiple Sclerosis, relaps - remittent from,
diagnosis from 1992, EDSS: 4,5, treated by immunomodulatory drug - Copaxon
from 02/07. Spastic teraparesis with cerebellum sympomatology, syndrom rear
portions, status post fracturam femoris sinistra (osteosyntesis).
Videos are provided at:
<http://www.youtube.com/watch?v=SNRPafFNgj0>
http://www.youtube.com/watch?v=SNRPafFNgj0
<http://www.youtube.com/watch?v=KCMvxKUBC7s>
http://www.youtube.com/watch?v=KCMvxKUBC7s
<http://www.youtube.com/watch?v=jdt-qxJ6-Rc>
http://www.youtube.com/watch?v=jdt-qxJ6-Rc
Conference Venue and accomodation: Vila Lanna, V Sadech 1, Praha 6
SCIENTIFIC IDEAS of workshop
In each country, different therapeutic approaches in similar cases are applied, but with the same aim – to help the patients as effectively as possible. It seems important to define this difference and to understand the cause of the difference. The aim of the workshop is to strengthen an open academic discussion in this field, to start long – term professional co-operation and to prepare a proposal of multi-centric study that will find the key principles for efficient treatment.
The case for an exploratory workshop
Physical rehabilitation in multiple sclerosis uses a variety of techniques and methods and it is difficult to clearly define its content. Neurophysiologic methods are used since 60ties last century (for example Bobath concept, proprioceptive neuromuscular facilitation, Vojta reflex locomotion) till present (1).
Originally these methods worked on the hierarchic model of the locomotion control and they were applied in physiotherapy as a so called facilitation approach. The attitude to the locomotion control kept changing with the development of neuroscience and imaging methods and it was demonstrated by different models. One of the latest ones is a so called system model (2) which forms the base for the so called task-oriented therapeutic approach, or in a wider concept problem solving approach, focusing on “specific” problems of an individual person/client/patient. Application of mention methods changed in this sense and new methods have been developed (for example Motor relearning programme – 3, 4, 5, 6).
Both these most frequently used approaches are based on senso-motoric learning. Therefore they have in common the fact that they apply different stimuli to achieve better locomotion and function. The facilitation approach puts the accent on manual application of stimuli (by propriocetive and exteroceptive stimulation, in Bobath concept e.g. by so called handling, in Vojta reflex locomotion by stimulating of so called initiation zones in precisely-defined positions) with the aim to facilitate and improve a given locomotive function, movement pattern or to start a locomotion programme, while the quality of execution is carefully controlled. The task-oriented approach makes use of mainly behavioral impulses or stimuli and a patient learns by repeating a given specific function in different environment/under different conditions; the ability to carry out a specific function is more important than the quality of the execution. It is possible to say that this approach draws on or is close to the International Classification of Functioning, Disability and Health (ICF) classification which evaluates function, disability as well as the extent of health in a wide context of patients’ environment.
We think that the choice of approach picked for the therapy depends not only on therapeutist’s knowledge, experience and preference but last not least on the RESULTS OF SCIENTIFIC STUDIE (concerning mainly of neuroplasticity and the possibility to influence the reorganization of the central nervous system, biochemical factors that promote learning and neural, evidence of structured programs of cognitive re-training) (8 – 10). If we look at the way of input/stimuli application to central nervous system in neurorehabilitation methods, we could find two basic groups of approaches that have the mode in common: facilitation (for example Vojta reflex locomotion, Brunnström, Rood, Bobath, PNF) and task oriented (for example Petö koncept, Perfetti, Constraint-Induced Movement Therapy, Motor Relearning Programme, “contemporary” Bobath concept, locomotor training, Dual Tasking).
Contemporary science uses still more and more sophisticated methods that help to explain the principles of the approaches. Based on fMRI studies, the main principle of task oriented approaches (task specificity of training and importance of training intensity - duration, frequency) could be supported. It has been confirmed that training produces task-specific functional changes or motor-learning in the spinal cord motor-generating circuitry (11, 12, 13). Enhanced training in sense of practicing task has an impact on the motor cortex (14, 15, 16, 17). Similarly the therapy, which used facilitation elements and general principles of sensory-motor learning like using repetition and variability of stimuli lead to changes (normalization of hemisphere’s cooperation) of brain activity (18).
Only few authors compared an effect of different approaches in multiple sclerosis. A randomized controlled crossover trial of Wiles 2001 compared home physiotherapy that focused more on problem solving (task oriented approach) and hospital physiotherapy that used more specific facilitation technique. Although home and hospital physiotherapy (task oriented and facilitation approach) did not differ in effect of treatment, the importance of the specific content of physiotherapy Whiles disused. Upper limb function improved as well as mobility. Several therapy techniques were directed at improved trunk control and head, neck, and trunk posture so potentially influencing arm function.
Lord et al. has compared two types of physiotherapy in a small group of MS patients (n=23). Ten patients received what was described as a facilitation approach while ten others had a more task-orientated approach. Patients received at least 15 sessions over 5-7 wk from the same therapist. A range of outcome measures was used including the 10-m timed walk, the Rivermead Mobility Index, Stride length, and the Rivermead Visual Gait assessment. The study showed no difference between the groups, which was not surprising given the small numbers, though both groups improved in measures of impairment and disability (p<0.05).
The workshop will be organized for specialists interested in mobility in neurological diseases (especially who has experience with treatment of multiple sclerosis), mainly for physiotherapists, medical doctors and professionals who are connected with the topic.
The workshop has following aims:
• To exchange knowledge and experiences among European research teams in the field of neurorehabilitation, which can primarily improve physical and psychical health dimension of MS people and secondarily improve social, cultural and institutional environment.
• To improve co-operation of experts on the topic and establish new research contacts between scientists form the top institutions in different European countries that devotes on multiple sclerosis.
• To bring together various specialists (medical doctors, physiotherapists, philosopher, ect.) for an open academic discussion on wide aspects of the issue of principles used in neurorehabilitation of MS people.
• To support involvement of young researchers and PhD. students.
• To develop and strengthen the work group for future network of cooperation.To initiate the discussion on new therapeutic possibilities in the comprehensive treatment of MS.
• To prepare a proposal project of a multi-centric study “The content of physical rehabilitation in multiple sclerosis across Europe” (intended for submission to EUROCORES) with following aims:
1. To define the key/principles of differences in the content of physiotherapy in MS across Europe, and to understand the cause of the difference.
a. to find whether therapeutic approaches differ in different countries
b. to find whether these differences are of global origin (historical, philosophical and cultural impact on health system)
c. to find whether these differences are of individual (subjective) origin, that means different understanding of neurophysiological and thus neurorehabilitation principles, different interpretations of experimental data from clinicians.
The results of the multi – centre study (a finding of the key principles for efficient treatment) will be a basis for preparation a document “Good Practice of Rehabilitation” that could improve standards in physical therapy across Europe in multiple sclerosis.
References
1. Faissner, A., Kettenmann, H., Trotter, J. A critical review of contemporary therapies. In: Comprehensive Human Physiology (Greger, R., Windhorst, U., eds.), Springer – Verlag, Berlin 1996, 96-108.
2. Umphred D.A., El-din D. Introduction. Theoretical Foundations for Clinical Practice (in: Neurological Rehabilitation. Fourth edition, ed. Umphred D.A.), Mosby, Inc., St. Luis Missouri, 2001: 3-31.
3. Taub E, Uswatte G, Pidikiti R. Constraint-Induced Movement Therapy: a new family of techniques with broad application to physical rehabilitation--a clinical review. J Rehabil Res Dev. 1999 Jul;36(3):237-51.
4. Shepherd R. B., Carr J. H. Neruological rrehabiltiation: the scientific basis of clinical practice. Kinésithérapie 2005; 38 – 39: 42 – 48.
5. Carr J. H., Shepherd R. B. Optimizing motor performance in gait following strike: training the lower imbs in support, balance and propulsion. Kinésithérapie 2005; 44 – 45: 20 – 30.
6. Shepherd RB, Carr JH. Neurological rehabilitation. Disabil Rehabil. 2006; 28 (13-14): 811-2.
7. Umphred D.A., Byl N., Lazaro R.T., Roller M. Interventions for Neurological Disabilities. In: Neurological Rehabilitation (ed. Umphred D.A.). Mosby, Missouri, 2001: 56 – 135.
8. Mulder T, Zijlstra W, Geurts A. Assessment of motor recovery and decline. Gait Posture. 2002 Oct;16(2):198-210.
9. Nadeau SE. A paradigm shift in neurorehabilitation. Lancet Neurol 2002; 1(2): 126-130.
10. Caceres F. LACTRIMS Leonor Gold Memorial Lecture: Past, present and future of neurorehabilitation in multiple sclerosis. Multiple Sclerosis 2008, 14 (suppl. 1): 27.
11. Edgerton VR, Courtine G, Gerasimenko YP, Lavrov I, Ichiyama RM, Fong AJ, Cai LL, Otoshi CK, Tillakaratne NJ, Burdick JW, Roy RR. Training locomotor network. Brain Res Rev. 2008 Jan;57(1):241-54.
12. de Leon RD, Hodgson JA, Roy RR, Edgerton VR. Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats. J Neurophysiol. 1998 Mar;79(3):1329-40.
13. Liepert J, Uhde I, Gräf S, Leidner O, Weiller C. Motor cortex plasticity during forced-use therapy in stroke patients: a preliminary study. J Neurol. 2001 Apr;248(4):315-21.
14. Liepert J, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C. Treatment-induced cortical reorganization after stroke in humans. Stroke. 2000 Jun;31(6):1210-6.
15. Gardner MB, Holden MK, Leikauskas JM, Richard RL. Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single-subject experimental design. Phys Ther. 1998 Apr;78(4):361-74.
16. Askim T, Indredavik B, Vangberg T, Håberg A. Motor network changes associated with successful motor skill relearning after acute ischemic stroke: a longitudinal functional magnetic resonance imaging study. Neurorehabil Neural Repair. 2009 Mar;23(3):295-304.
17. Johansen-Berg H, Dawes H, Guy C, Smith SM, Wade DT, Matthews PM. Correlation between motor improvements and altered fMRI activity after rehabilitative therapy. Brain. 2002 Dec;125(Pt 12):2731-42.
18. Rasova K, Krasensky J, Havrdova E, Obenberger J, Seidel Z, Dolezal O, Rexova P, Zalisova M. Is it possible to actively and purposely make use of plasticity and adaptability in the neurorehabilitation treatment of multiple sclerosis patients? A pilot project. Clin Rehabil. 2005 Mar;19(2):170-81.
19. Wiles CM, Newcombe RG, Fuller KJ, Shaw S, Furnival-Doran J, Pickersgill TP, Morgan A. Controlled randomised crossover trial of the effects of physiotherapy on mobility in chronic multiple sclerosis. J Neurol Neurosurg Psychiatry. 2001 Feb;70(2):174-9.
20. Lord SE, Wade DT, Halligan PW, A comparison of two physiotherapy treatment approaches to improve walking in multiple sclerosis: a pilot randomized controlled study, Clin Rehabil 1998; 12:477-86.
List of proposed participants:
1. Assistant Professor Dr. Rasova Kamila, Ph.D., PT, Department of rehabilitation, 3rd Medical Faculty Charles University in Prague, research coordinator
2. Associate Professor Hlustik Petr, MD, Ph.D., Department of Neurology and Department of Radiology, Medical Faculty and Faculty Hospital Olomouc, expert in neuroscience
3. Professor Hogenova Anna, philosopher, Department of Philosophy and Civics, Pedagogical Faculty Charles University in Prague, philosopher
4. Assistant Professor Dr. Zounková Irena, PT, Department of Rehabilitation and Sports Medicine, 2nd Medical Faculty Charles University and Faculty Hospital Motol in Prague, expert in Vojta reflex locomotion
5. Mariusz Kowalewski, MD - neurologist, MS Rehabilitation Centre in Borne Sulinowo, Poland, representative of Poland rehabiltiation
6. Małgorzata Stachowiak, PT, MS Rehabilitation Centre in Borne Sulinowo, Poland
7. Dr. Peter Feys, PT, REVAL, University of Hasselt-PHL, Belgium, experience researcher in multiple sclerosis
8. Dr. Anna Kelemen PhD, consultant in the National Institute for Neurosurgery, candidate for the Department of Neuro-rehabilitation in the Pető Institute, Magyar, representative of conductive education
9. Johanna Jonsdottir ScD, MS PT, Neurorehabilitation at the Don Gnocchi Foundation, Milan, expert in using ICF model in multiple sclerosis
10. Davide Cattaneo MS PT, head of Gait and Balance clinical laboratory at the Don Gnocchi Foundation, Milan, physiotherapist who uses task oriented approach
11. Claudio Solaro, Claudio Solaro, MD (I - Genova), specialist in outcome measures
12. Prof. Dr. T. Henze, Reha-Zentrum Nittenau - Rehabilitationszentrum für Neurologie - Geriatrie – Onkologie, Nittenau, Germany, specialist in understanding of rehabilitation
13. PD Dr. C. Heesen, Institute of Neuroimmunology and Clinical MS Research (INIMS), Hamburg, Germany, expert in immunology in multiple sclerosis
14. Dr Susan Coote, MISCP, Department of Physiotherapy, University of Limerick, Ireland, representative of Ireland physiotherapeutic approach
15. Tori Smedal, Haukeland University Hospital, Physiotherapy Department, Neurorehab Unit, Bergen, Norway, representative o Bobath concept
16. Vincent de Groot, VU Amsterdam, Netherlands, researcher and representative of Neatheraland approach
17. H. Van Tongeren, Denmark, expert in Dual Tasking and representative of Denmark approach
18. B. Gattlen, Switzerland, physiotherapist skilled in Proprioceptive neuromuscular facilitation, representative of Switzerland approach
19. Claude Vaney, MD, Montana, Switzerland, researcher, specialist in understanding of rehabilitation
20. C. Santoya, Spain, physiotherapist skilled in Perffeti approach, representative of Spain approach
21. Anders Romberg, PT, Turku/Masku, Finland, research in rehabilitation, representative of Finland approach
22. Merje Proosa, PT, Talinn, Estonia, representative of physiotherapy in Estonia
23. Dr. Margaret Mayston, PT, Neuroscience, Neurophysiology, University College London, experienced researcher, author of commentaries in field of content of rehabilitation
