Primary-Progressive Multiple Sclerosis (PPMS) - A Case Study

Abstract

Purpose:

Case Presentation:

Intervention:

Outcomes:

Introduction

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Client Characteristics  

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Examination Findings

Subjective Assessment

Chief Complaint: Michelle has concerns about taking her dog for daily walks in the summer. She is afraid of losing her balance and worried she won’t have enough energy to complete the walks. Michelle is also having trouble with the stairs in her house. She finds her legs weak and she is tired by the time she reaches the top of the stairs.

History of Present Illness:

Medical diagnosis: PPMS active with progression

• MRI to confirm and identify areas of lesions in the brain
• Positive lumbar puncture test
• Positive evoked potentials test

Treatment to Date: No previous history of physiotherapy treatment.

Current Symptoms:

• Impaired mobility
• Weakness and stiffness in the legs, the right leg worse than the left.
• Decreased attention, and memory
• Pins and needles in the feet
• Urgency incontinence  
• Fatigue
• Difficulty with normal gait
• Balance impairments

Past Medical History:

• Diagnosed with active PPMS with out progression 2 years ago
• Diagnosed with active PPMS with progression 2 weeks ago
• Comorbidities:
  • Depression - diagnosed 1 year ago
    • Prescribed medications
    • Weekly visits to psychiatrist to help with depressive symptoms
  • Hypertension - diagnosed 5 years ago

Medications:

Oral Paroxetine - 20mg, once a day for depressive symptoms

Norvasc (Amlodipine) - 5mg, once per day for hypertension

Ocrevus - 600 mg intravenous infusion every six months

Social History: Michelle lives in Mississauga in a house with 2 steps to get into the house as well as 12 steps to get to the second floor. She lives there with her husband, 2 children and family dog. She has been a work-from-home accountant for the last 15 years. Michelle enjoys working from home but has noticed in the last few months that she has trouble concentrating on her work and thinks her memory has gotten worse. Her family recently moved to Mississauga from Ottawa in the last year, and friends and  distant family are still located in Ottawa. Michelle enjoys walking her dog daily, reading and watching movies. However, she finds when she sits in the same position for a long period her pain and discomfort increases.

Family History: History of hypertension on maternal side

Functional History: Michelle was previously able to ambulate 45 minutes with dog without use of gait aid. She was also less fearful of community ambulation. Michelle also previously enjoyed gentle weight-bearing resistance training at her local gym, she would often go twice a week for about 30-45 minutes. Michelle was also able to walk up a flight of stairs without fatigue. She had no problems with her daily activities such as grooming, cleaning and cooking. However, she found carrying laundry up the stairs quite difficult but often received help from her husband or kids.

Current Functional Status: Michelle has been cutting back on the length of her workouts at the gym as she now finds resistance training more painful and difficult due to balance impairments. Michelle has also become more fearful of community ambulation due to fear of falling, and currently walks around the block. She only walks the dog twice a week due to her balance and stability deficits and will only go if her husband or one of her children accompanies her. Michelle is often fatigued and feels weak after walking up a flight of stairs and is unable to carry her laundry up the stairs anymore. She still manages her daily activities well, but finds herself tired if she does a large clean of the house.

Patient Goals:

1. Michelle would like to get back to walking her dog daily, independently.
2. Michelle would also like to limit the progression of her symptoms.
3. Michelle would like to improve her strength to be able to walk up stairs better.

Objective Assessment

Range of Motion

UE - WNL

LE - Table #1

Joint	Movement	Active ROM - LEFT	Passive ROM - LEFT	Active ROM - RIGHT	Passive ROM -RIGHT
Hip	Flexion	100	105	90	100
Hip	Extension	10	15	10	15
Hip	Adduction	20	30	20	30
Hip	Abduction	40	45	40	45
Hip	External Rotation	30	40	30	40
Hip	Internal Rotation	30	40	30	40
Knee	Flexion	125	130	115	125
Knee	Extension	0	-5	-5	-5
Ankle	Plantar flexion	40	45	35	45
Ankle	Dorsiflexion	10	15	5	10
Ankle	Inversion	15	20	10	15
Ankle	Eversion	5	10	5	10

Spasticity

Modified Ashworth Scale

UE - WNL

LE - Table #2

Muscle Group	Left Limb	Right Limb
Hip Flexors	0	0
Hip Extensors	0	0
Hip Adductors	0	0
Hip Abductors	0	0
Knee Flexors	1	1
Knee Extensors	1	1
Ankle Plantar Flexors	1+	2
Ankle Dorsiflexors	1	1+

Strength

Manual Muscle Testing (MMT)

UE - WNL

LE - Table #3

Muscle Group	Score Left Limb	Score Right Limb
Hip Flexors	4+	4+
Hip Extensors	4	4
Hip Adductors	4	4
Hip Abductors	4	3+
Hip External Rotators	4	3+
Hip Internal Rotators	4	3+
Knee Flexors	4	4-
Knee Extensors	4	4-
Ankle Plantar Flexors	4	4
Ankle Dorsiflexors	4-	3+
Ankle Inverters	4-	4-

Neurological

Gait

Balance

Fatigue

Clinical Impression

Problems list

• Body structure function
  • Reduced balance due to decreased proprioception and weakness in lower extremities.
  • Impaired memory due to disease progression.
  • Impaired sensation due to irreversible destruction of the myelin sheath and axons of nerves.1
  • GAIT
  • Increased muscle tone/spasticity around ankle and knee joint due to demyelinated nerves in brain and spinal cord.2
  • MUSCLE STRENGTH
• Activity
  • Difficulty climbing stairs due to fatigue and SOB.
  • Urgency incontinence due to weakened sphincter muscles.
  • Reduced attention span due to fatigue and cognitive deficits.
• Participation
  • Unable to walk her dog due to impaired mobility and fatigue.
  • Avoids resistance training due to pain and lack of stability.
  • Difficulty concentrating at work due to impaired memory and attention issues.
• Personal factors
  • Patient is fearful of falling.
  • Reduced productivity at work due to pain during prolonged positioning.
  • Easily fatigued.
  • Diagnosed with depression 1 year ago.
• Environmental
  • The patient's home has 2 steps to enter, and 12 steps to reach the second floor.

References

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Original Editor - Krystin Rudge Top Contributors - Brooke McIntosh, Krystin Rudge, Erin Locke, Crystal Robello, Cindy John-Chu, Uchechukwu Chukwuemeka, Sahil Sareen, Kim Jackson and Carina Therese Magtibay