Case Study IX

1. Case Study IX Vanessa Trevino, SPT Cynthia Simpson, SPT

2. Patient Information • Ann Kling • 36 y/o ♀ • Full-time PT w/busy lifestyle • Caretaker of husband who undergoes chemotherapy

3. Patient Symptoms • Frequently Fatigued • Recurrent burning pn LLE • L ankle has been problematic for past 6 months • L Ankle turned on her yesterday

4. Patient Symptoms Continued • 1 week later: • Pt. falls in hospital bathroom • Referred to see neurologist by husbands MD

5. Neurological Exam • A&O x 3 • Dermatomes WNL RLE; diminished L4-S2 LLE • Myotomes WNL RLE; diminished L4-S2 LLE • Impairment of CNIII- Oculomotor • What does this CN perform? • When used with the PPRF, MLF, & CNVI, it helps with what action? • Conjugate Horizontal Gaze • Know this for practical!!! HINT !!! HINT!!!

6. Neurological Exam • Dysarthria- what is dysarthria??? • Other Exams: • Beck Depression Scale • MD ordered MRI & lumbar puncture

7. Physical Exam • Vitals: • HR97, BP 92/59, RR16 • Hyper-reflexia LLE • Progressive muscle weakness of LLE • Paresthesia • MMT: 3+/5 LLE; 4+/5 RLE • Gait dysfunction 2° balance & coordination deficits • ROM: limited LLE 2° MM Weakness • Berg Balance Scale

8. Hyper- reflexia LLE Progressive Muscle Weakness Paresthesia 3+/5 LLE; 4+/5 RLE Gait Dysfunction 2° balance & coordination deficits. Impairment of CNIII- Oculomotor Dysarthria Dermatomes – L4-S2 Myotomes – L4-S2 Any thoughts on the DX? REVIEW

9. Diagnosis:Multiple Sclerosis (MS)

10. What is MS? • According to Goodman, Fuller, & Boissonnault, MS is… • A progressive neurological disease caused by sclerotic plaques throughout the central nervous system.1 • These plaques or lesions slow and block neural transmissions resulting in weakness, sensory loss, visual dysfunction, and other symptoms.

11. MS continued • Historically, this was difficult to diagnose but with MRI technology, diagnosis can be made with the first attack.2 • Bright spots are new lesions • Dark spots are chronic lesions

12. Types of MS- According to Merck • Relapsing-remitting pattern: Relapses (when symptoms worsen) alternate with remissions (when symptoms are stable). Remissions may last months or years. Relapses can occur spontaneously or can be triggered by an infection such as influenza.3 • Primary progressive pattern: The disease progresses gradually with no remissions or obvious relapses, although there may be temporary plateaus during which the disease does not progress.3 • Secondary progressive pattern: This pattern begins with relapses alternating with remissions, followed by gradual progression of the disease.3 • Progressive relapsing pattern: The disease progresses gradually, but progression is interrupted by sudden relapses. This pattern is rare.3

13. Practice Patterns4 • Practice Pattern Neuromuscular 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling • Practice Pattern Neuromuscular 5E: Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System

14. Evaluation: Nagi Disablement Model • Pathology: Multiple Sclerosis (MS); primary progressive stage • Impairment: muscle weakness, balance & coordination deficits, increased risk of falls, vision impairment, • Functional Limitation: inability to engage in ADL’s w/o fatigue, impaired mobility • Disability: Unable to be primary caregiver for husband, unable to work full time as PT

15. Prognosis • Fair : • PPMS is considered more ominous = worst type to have • Had more than 1 symptom @ onset • Prognosis is fair because Anne is still functionally capable of taking care of her husband and working full time. She is young and in the early stages of the disease process. • Statistics: • After 10 yrs, only a minority are still working. • After 15 yrs p dx, 50% require AD for amb • At 20 yrs. p dx, 50% require WC

16. Intervention • Hydrotherapy/aquatic therapy • Water temp: What should it be? • 82°-88°F • Min-mod 50-70% STR training • ROM Ex. to help prevent spasticity • Postural control/ Balance exercises • Gait training NBQC • Pt edu: She already has knowledge of dz since she is a PT, discuss what to do for exacerbations, keeping environment safe, and monitoring progression of MS.

17. Goals • LTG 1: Pt to increase mm STR LLE to 4/5 in order to amb c SPC safely in home and work environments in 4 weeks • STG: Pt exhibits overall 4-/5 LLE MMT in 2 wks. • STG: Pt to demonstrate proper use of NBQC on uneven surfaces and stairs in 1 wk. • STG: Pt to demonstrate proper use of SPC on uneven surfaces and stairs in 3 wks. • LTG 2: Pt to balance SBA in tandem stance for 2 minutes in 4 wks in order to perform ADLs in home safely. • STG: Pt to maintain balance c min assist in tandem stance x 30 sec in 1 wk. • STG: Pt to maintain balance c SBA in tandem stance x 1 minute in 2 wks.

18. PT Implications • Monitor fatigue • Use modified fatigue index • Give frequent breaks • Try to schedule a.m. tx • Monitor HR & BP responses; they may be blunted • Ensure plan is individualized

19. Outside Services • Environmental Exam ( AC, ergonomic equipment) • Pharmocological (Interferon drugs) • Counseling • Psychosocial issues • Social services • Caregivers for Ann & husband • Speech Therapy (dysarthria) • Refer to National Association for Visually Handicapped • Help with vision issues

20. References: • Goodman, Boissonnault, Fuller. Pathology: Implications for the Physical Therapist. 2 ed., Saunders, 2003. • O’Sullivan,S. Schmitz,T. Physical Rehabilitation. 5th ed., F.A.Davis, 2007. • Merck Manuals.Multiple Sclerosis. <http://www.merck.com/mmhe/sec06/ch092/ch092b.html> 3 Nov 2008. • American Physical Therapy Association. Guide to Physical Therapist Practice. 2 ed., 2003.

21. Always Remember it’s Patient CARE