MS - case study

EP II Case Study

MULTIPLE SCLEROSIS

İbrahim Bostan - 309392014-2015Supervisor : R.M.

Multiple Sclerosis

- Chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and spinal cord (Gaby,1997)

- High Risk Factors

InfectionPhysical injuryEmotional stressExcessive fatiguePregnancyPoor state of health (Sibley,1995)

Multiple Sclerosis

Name Characteristics

Relapsing-RemittingMultiple Sclerosis(RRMS)

Symptom flare-ups followed by recovery;stable between attacks

Secondary-ProgressiveMultiple Sclerosis(SPMS)

Second phase of RRMS; progressiveworsening of symptoms with or withoutsuperimposed relapses; treatments maydelay this phase

Primary-ProgressiveMultiple Sclerosis (PPMS)

Gradual but steady accumulation ofneurological problems from onset

Benign Few attacks and little or no disability after20 years

Progressive-RelapsingMultiple Sclerosis(PRMS)

Progressive course from the onset,sometimes combined with occasionalacute symptom flare-ups

Malignant or FulminantMultiple Sclerosis

Rapidly progressive disease course

Types of Multiple Sclerosis

Multiple Sclerosis

➲ Characterized by chronic inflammation, demyelination, and gliosis (scarring) in the CNS

➲ Initially triggered by a virus in genetically susceptible individuals

➲ Then antigen-antibody reaction leads to demyelination of axons (Mattner,2000)

Initially the myelin sheaths of the neurons in the brain and spinal cord are attacked, but the nerve fiber is not affected

Patient may complain of noticeable impairment of function

Myelin can regenerate, and symptoms disappear, resulting in a remission (Mikaeloff,2004)

Multiple Sclerosis

Motor manifestations

➲ Weakness or paralysis of limbs, trunk, and head

➲ Diplopia (double vision)➲ Scanning speech➲ Spasticity of muscles

Sensory manifestations

➲ Numbness and tingling➲ Blurred vision➲ Vertigo and tinnitus➲ Decreased hearing➲ Chronic neuropathic pain

And other manifestations

➲ Constipation➲ Spastic bladder➲ Sexual dysfunction

Cerebellar manifestations

➲ Nystagmus ➲ Involuntary eye

movements➲ Ataxia➲ Dysarthria➲ Lack of coordination in

articulating speech➲ Dysphagia➲ Difficulty swallowing

Multiple Sclerosis

Treatment ➲Medications➲Chemotherapy➲MRI devoted to neurological imaging: using three-dimensional imaging that determines whether a patient's condition is worsening.

Multiple Sclerosis

Physiotherapy

Relieve spasticity Increase coordination Train the patient to substitute unaffected muscles for impaired ones Increase life standard

General Data of Member's

Name: M.C.

Date of Birth: 28.03.1949

Weight: 57 kg Height: 1,57 m

Marital Status: Married Sex: Famale

Job: Retired (Administrative Assistant)

Hobbies: Read a book, watch TV, meet/talk with her friends

BMI: 23,17 kg/m² (Normal)

Subjective Examination

Clinical Diagnosis:

Relapsing Remitting Multiple Sclerosis

Main Problem:

Patient's main problem is; can't walking independent, decrease activities of daily living, tension of muscles, sometimes disorder of talking, sometimes disorder of control and balance on static standing position.

Clinical History:

In 1992 she felt numbness and tingling on her right hand.(first symptom of disease). Approximately 6 years later patient felt muscle strenght deficit on her upper limb and 2 months later it recovered.

In 2006, she has a first outbreak on left side (upper and lower extremity). And she went to hospital and they made complementary diagnostic test, MRI. Whey were inconclusive(unresult). In 2007, they did lumbar puncture and as a result of lumbar puncture, she has a multiple sclerosis. In same year, she took medicines for multiple sclerosis. In 2009, she had strenght of muscles on right leg. From 2009, she had multiple outbreak on right leg. That effect strenght (like a spasticity). In 2010, patient had outbreak, in both of legs. In 2012, she had outbreak, in right lower extremity.

Clinical History:

Patient had started to Pedagogical Clinic of Physiotherapy University of Fernando Pessoa at 03.08.2010. She is coming since that date to treatment.

And from last outbreak, patient is coming to Pedagogical Clinic of Physiotherapy

on University of Fernando Pessoa twice a week.

Questions of General Health

Background:

She has a high cholesterol.

General health:

Patient is controlling to own disease with medicines.

Habits:

The patient's level of smoking or alcohol habits are so important in terms of physical therapy does not affect the process.

Medicine

Surgery

Name Indication Often

Cipralex Anxiety desorder Once a Day

Avonex Spasm and prevention of infection

Once a Week

Tisanidina Muscle Relaxing Once a Week(Mondays)

Brufen Painkiller When she takes the injection

Ator Vastatain For Cholesterol Once a Day

Surgery Date

Left Eye (tear of vein) 1976

Left Ankle Fracture (internal fixator)

2003

Body Chart

Pain Scale

Right Sole: Rest: 0 Act : 10

Lower Ext: Rest: 10 Act : 10

She has pain only during activity on sole. On lower extremity she always has pain. And also she has a pain in lumbar area but patient couldn't say number for this. But when she has a lumbar pain she can't stand up; because pain is hard and boring. She waking up almost all night from own sleep because sometimes pain can be very irritaing. We wanted to take separately scale of pain but patient could say just as own leg. Patint is feeling to pain on own muscle Also she hasn't got a pain on hand but sometimes she is loseing hand strenght. But patient suffering from pain mostly right foot.

Objective Examination

Formal/Informal Exam:

Face: Patient has a willing face and sometimes we can understand on her

face, she has a pain.

Posture: Her posture is so spastic, especially right extremities; especially,

lower extremity.

Walking: She can walking with someone's support 10-15 metres. But she is

not able to walk independent.

Objective Examination

Inspection / Observation / Palpation

Patient has a tension on under of left foot between 4.-5. MTP joints. Skin usually

fat. She always cold. It is about patient's main disease. We didn't see manifest

swollen or colour difference. She can stay on standing position 20-25 seconds

independent. When she is walking she is doing huge hip rotation, she provide so

that stepping. She can walk with support several minutes. But this walking also so

difficult and tiring for this patient. So we are resting several times when we are

walking with patient. And also about patient posture; patient's feet on supination

position both. On knees have a big tension, about spasticity.

Objective Examination

Posture Analysis and Gait Exam:

We could evaluate to patient supine position and standing

position sometimes. Patient's feet on supination position. Head

anterior tilt a little bit. Her legs extension, kness extension and feet

plantar flexion position cause lower extremity spacticity. When she

is walking, she is doing more hip rotation both of hips (for right hip

more). For stepping she is taking own trunk to back and after she is

taking a step.

Objective Examination

Assessment of Mental State: Glasgow Coma Scale

Eye opening reponse: Spontaneously

Best verbal response: Oriented to time, palace and person

Best motor response: Obeys commands

Score : 15

Objective Examination

Scale of AshworthScore Modified Ashworth Scale Bohannon & Smith (1987)

0 No increase in muscle tone

1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension

1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM (range of movement)

2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

3 Considerable increase in muscle tone passive, movement difficult

4 Affected part(s) rigid in flexion or extension

Objective Examination

Part of Body First week of Treatment

Last week of Treatment

Lower Ext. (Both)

3 2

Right Hand 1 1

Left Hand 0 0

Neck/Trunk 0 0

Objective Examination

WHO-QOL BREF-26

This quality of life exam prepared by World Healt Organization. And

this exam is most comman and useful exam.

For our patient; answers generally; moderaty levels.

(Only 21th question didn't ask. Because it it private question)

Objective Examination

Sensibility Exam

Patient has a sensibility disorder almost all extremities. Especially; right

extremities and most important extremity is right lower extremity. Because lower

extremities are for ambulation and when person has a sensibility disorder, ambulation

can be so difficult for person. Because person must feel position of extremities and

another somethings.

Objective Examination

Reflex Exam

Patient's reflexes are increased on upper right upper extremity but on other upper

extremity is normal. For patella and aschill; reflexes are decreased both od lower

extremities. It is about patient's lower extremity spasticity. In pathological reflex; on

right side tests are positive; on left side babinski positive but hoffmann and

palmomental reflexes are in normal levels.

Objective Examination

Cranial Nerve Exam

Patient's all cranial nerves tests are normal.

Nerve Status Nerve Status

1-Olfactorius Normal 7-Facial Normal

2-Opticus Normal 8-Vestibulo cochlearis

Normal

3-Oculamotorius Normal 9-Glosso pharingeus

Normal

4-Trochlearis Normal 10-Vagus Normal

5-Trigeminus Normal 11-Accesorrius Normal

6-Abducens Normal 12-Hypoglossus Normal

Objective Examination

Mobilization State Exam

Patient has a spasticity, more right side. We saw clasp knife and cogwheel reflex on right lower extremity; on left lower extremity seen only clasp knife reflex. So we can say left side better than right side.

Objective Examination

Coordination Exam

Every coordination exams almost successfully about upper extremity. She couldn't

do coordination exams about lower extremity. Because her spasticity blocked her

and pain doesn't let to her.

(Tests had did; open eyes and close eyes; results were same)

Tests Right LeftFinger to nose + +

Finger opposition

+ +

Pronation/Supination

+ +

Heel to knee - -

Objective Examination

Barthel Index

Before Treatment: 60 (First week of treatment)After Treatment: 65 (Last week of treatment)

Patient most of problem is ambulation activities. Generally she is

successful functional activities. So our first mission is improve the

ambulation activities. And this is improving now.

Objective Examination

Berg Balange Scale

Before Treatment: 17 (First week of treatment)After Treatment: 21 (Last week of treatment)

Patient's balance situation was improved. Stand up to sitting and sitting to stand up

functions and transversion, mobility and ambulation are so easier than past for

patient. But scores are so variable daily before and after treatment. This scores

are done after treatment. Because control of spacticity so difficult for patient

before treatment and also cold weather is stimulated patient's spacticity.

Targets of Treatments

In Short Time: - To provide normal muscle tone - To improve control - To improve mobility of trunk and upper and lower extremities - Keep the standing position a long time - To improve upper and lower extremities static and dynamic balance

In Long Time: - As possible as independent getting up and ambulation - To provide function of hand - Improve Activities of Daily Living - Improve Quality of Life

Plan of Treatment

Mobilization (Jones, 1999)

Lower Ext., Patellar Mobil, Right Upper Ext.

Strenght (Petejan, 1996)

Lower Ext., Right Upper Ext.

Bridging (Fox, Cappos, Cree; 2011)

Strengh of Abdominal and Hip Exten., Preparing to walking

Walking Exercise on Paralel Bar (Lord, 1998)

Stretch (Nordez,2008)

for more flexible muscle, espec; gastro, quadriceps and lumbar exten.

Muscle Realigment (Bobath,2009)

inhibition of muscles

Hot Pack (Kitchen,2003)

Vasodilation, Analgesic effect and local relaxation; especially, relief of pain and tension

Massage (Kesiktas,2004)

Relaxing of muscles and inhibition of spacticity; gastro, quuadriceps, right forearm, low back

Contraction-Relaxing (Bobath,2009)

Inhibition of spastic muscles

Plan of Treatment

References

Pathology Gaby AR. Commentary: Multiple sclerosis. Nutrition & Healing 1997;4:1-11. Sibley WA, Bamford CR, Clark K. Clinical virus infections and multiple sclerosis. Lancet 1985; i:1313-1315 Mattner F, Smiroldo S, Galbiati F, et al. Inhibition of Th1 development and treatment of chronic-relapsing experimental allergic

encephalomyelitis. Eur J Immunol 2000;30:498-508. Mikaeloff Y, Suissa S, Vallee L. et al First episode of acute CNS inflammatory demyelination in childhood: prognostic factors for

multiple sclerosis and disability. J Pediatr 2004. 144246–252.252 [PubMed] Compson A. Genetic susceptibility to Multiple Sclerosis in MC Alpines's Multiple Sclerosis. 3rd ed. London: Churchill Livingstone

1998.

Treatment Nordez A, Gennisson JL, Casari P, et al. Characterization of muscle belly elastic properties during passive stretching using transient

elastography J Biomech, 2008; 6: 2305–2311 Kesiktas N, Paker N, Erdogan N, et al. The use of hydrotherapy for the management of spasticity. Neurorehabil Neural Repair 2004;

18: 268–73. Jones R, Davies-Smith A, Harvey L. The effect of weighted leg raises and quadriceps strength, EMG and functional activities in

people with multiple sclerosis. Physiotherapy 1999;85(3):154 1.� Petajan JH, Gappmaier E, White AT, Spencer MK, Mino L, Hicks RW. Impact of aerobic training on fitness and quality of life in

multiple sclerosis. Annals of Neurology 1996;39(4): 432 1. [MEDLINE: 8619521]� Lord SE, Wade DT, Halligan PW. A comparison of two physiotherapy treatment approaches to improve walking in multiple sclerosis:

a pilot randomized controlled study. Clinical rehabilitation 1998; 2(6):477 6. [MEDLINE: 9869251]� Fox R, Kappos L, Cree B, et al, editors. Effects of a 24-week natalizumab treatment interruption on clinical and radiologic parameters

of multiple sclerosis disease activity: the RESTORE study. 5th Joint Triennial Congress of the European and Americas Committees for Treatment an d Research in Multiple Sclerosis, October 19 2;2011; Amsterdam, The Netherlands. �

Kitchen, S., 2003. Electroterapia - Prática Baseada em Evidencias. 11ª edição ed. s.l.:Manole. Bobath, B. (2009). Hemiplegia no adulto. Avaliação e Tratamento. São Paulo: Manole.

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