Let’s talk about patient care and rehabilitation in MS. What are the key disabilities you are trying to mitigate?
Mrs. Marks: In the patient with multiple sclerosis, there are many things that the patient might present with. And some of the key disabilities that we would want to mitigate include visual loss, muscular weakness, bowel, and bladder dysfunction, and then also personality, behavioral, and cognitive changes, so you would employ a whole plethora of disciplines to assist with making sure those functions are optimized. Firstly to address visual disturbances you would work with ophthalmology as well as the neuroscience department to identify lesions and what part of the brain they’re affecting to make sure that the optic nerve is not permanently damaged, and provide the patient with any assistive devices they might need to help them restore or retain the vision that they do have.
In terms of cognitive disabilities, problems with memory loss occupational therapy can help with that, with doing different exercises to regain memory function, and it depends on what area of the brain is affected. Sometimes speech is involved. Patients might have expressive or receptive aphasia, or difficulty swallowing, or difficulty pronouncing words, such as dysarthria. Speech therapy would be involved in exercising…involved in working with the patient to do exercises to regain that speech function and also to overcome that disability of not being able to express themselves. You could also employ different methods of communication so that wasn’t affected until the speech is regained.
Physical therapy is integral. One of the major complications with MS is that inability to move your muscles, and if you have damaged nerves to whatever muscles one of the consequences is the muscle atrophies, so there are certain therapies involved. Sometimes we use electrical stimulation to the muscle sites to prevent that atrophy from occurring, but if the nerve is permanently damaged then you would want to do range of motion of exercises, involve the family, and get whatever assistive devices that patient might need onboard early so that they can maintain optimal function, in terms of their mobility. It’s a team effort and the end goal is just to make sure that the patient is functioning as best as possible with whatever stage of the disease they might be at.
From a physical and occupational therapy perspective, what are some of the key therapeutic techniques that you employ?
What is your approach for a patient who may be in remission?
Mrs. Marks: When a patient is experiencing an acute episode of a multiple sclerosis attack, which means that they’re in relapse, it can be very painful. They could have a myriad of symptoms related to the attack from numbness to severe pain. Our main focus during that point is symptomatology, so alleviating those symptoms. We’re not really focused on the long term at that point, because the patient is currently uncomfortable and unable to function, and we want them to return to a functional level, so pain management is one of the key things that we focus on when they’re experiencing an attack, also that high dose corticosteroid therapy is imperative because one of the reasons they’re experiencing the relapse is because of the inflammatory demyelinating process so we want to decrease that inflammation so the symptoms now are reduced then you can look towards getting them on long term physical therapy, whether an outpatient or in-patient basis as well as occupational and speech, but in the acute phase our main goal is to relieve pain and decrease inflammation.
What are some of the key cognitive and neuropsychiatric challenges in these patients?
Mrs. Marks: I think education is one of the key things we have to focus on in a patient with remission because patients, as I mentioned before, might feel better and want to stop therapy because of some of the adverse side effects associated with the immunosuppressive drugs. But it’s key to educate the patient and explain that if they were to do so they may have a relapse and the disease might progress even further than they had anticipated, so educating the patient, making sure they follow up with appointments, assessing for any kind of new symptomatology no matter how faint or vague it might be, and also educating family members to be supportive during that phase, and understanding that even though you’re in remission it doesn’t mean that the disease is cured or has gone away, and there’s always the potential for symptomatology to return and even worsen.
Mrs. Marks: Patients with multiple sclerosis may have lesions in the frontal lobe of the brain resulting in severe cognitive behavioral changes. They may even become psychotic or display dangerous behavior. One of the key elements of managing a patient who’s had these lesions is placing them temporarily on antipsychotic medication. It would be necessary to employ psychotherapists and also to educate the family that this might be a temporary symptom and not to become frustrated with this in therapy, and to also provide them with supportive care and resources that they may turn to in order to manage themselves as well as the patient through this very tough time.