Case Study 16: Patient With Multiple Sclerosis

EXAMINATION

History

• Demographic Information:

  The patient is a 57-year-old right-handed female with secondary progressive multiple sclerosis. She presents to outpatient clinic after a self-reported decline in function. MRI reported no active lesions.

• History of Present Illness:

  The patient has multiple sclerosis, which was diagnosed 20 years ago. Before this most recent episode, she has not had an exacerbation of symptoms in the past 5 years. Currently she reports feeling weaker in her lower extremities and is experiencing increased instances of loss of balance with ambulation. She states that it is getting harder to ascend stairs and inclines. Patient is walking community distances with walking poles. She works at a childcare center and is now thinking she may not be able to perform her job responsibilities.

• Medical History:

  Patient reports history of bladder urgency, occasional dizziness, and falls. She reports chronic low back pain and spasticity, which are managed with Botox injections. No history of surgeries or hospitalizations.

• Current Medications:

  Tysabri, Ampyra, magnesium, vitamin D, and Botox injections.

• Social History:

  Patient is married, lives with spouse, and works as a daycare provider. Her husband is very supportive. Patient is a former high school track star and avid hiker who also enjoys spending time with her grandchildren and traveling.

• Living Environment:

  Patient lives in a multiple-level home with one flight of stairs with one rail on the left going up. She has the following durable medical equipment: gait belt, bilateral (B) walking poles, cane, and SaeboStep device.

• General Health Status:

  Good

• Prior Level of Function:

  Independent for short distances of ambulation. Modified independent with bilateral walking poles for community distances.

Systems Review

• Cardiovascular/Pulmonary System:

  • Blood Pressure: 124/76

  • Pulse: 64 beats per minute

  • Respiratory Rate: 18 breaths per minute

• Musculoskeletal System:

  • Height: 5 ft, 5 in.

  • Weight: 135 lb

  • Gross Symmetry: Normal anatomical symmetry

  • Gross Strength: The patient presents with gross limitations in the strength of both UEs and both LEs, with greater limitations in the left upper extremity (UE) and lower extremity (LE).

  • Gross Range of Motion (ROM): Within normal limits (WNL) bilaterally

• Neuromuscular System:

  • Sensation: Impaired light touch and proprioception left lower extremity

  • Coordination: Impaired upper and lower extremities with dysdiadochokinesia

  • Spasticity: Impaired (B) lower extremities

  • Postural Control: Intact in sitting and standing

  • Balance: Impaired static and dynamic standing balance. Details follow.

  • Gait: Ataxia with right LE. Weakness and compensatory strategies seen in left LE, requires supervision without an assistive device.

  • Cognition: Mild impairments with processing speed.

• Integumentary System:

  Intact, no evidence of skin breakdown.

Tests and Measures: Initial Examination

• Vision:

  Gaze stability, smooth pursuits, convergence, saccades, VOR cancellation: negative

• Strength:

  Results of the manual muscle test are presented in Table CS16.1.

  See Figure CS16.1 for an example intervention to address hip flexion weakness.

• Range of Motion:

  WNL throughout bilateral UEs and LEs

• Gait Assessment:

  • Ataxia, scissoring, decreased gait speed, ...