EFFECTIVENESS OF PHYSICAL THERAPY HANDLING MULTIPLE SCLEROSIS.
lose to 86 per cent of patients suffering from multiple sclerosis undergo pain that may be either acute or chronic. Physical therapy has been known to reduce severity of signs and increasing movement function of MS patient in times of remissions. Neurological rehabilitation, use of aerobic exercises, training on resistance and balance on exercises result in decreasing levels of fatigue and increase locomotion functions of a patient.
This case report seeks to analyse effectiveness of physical therapy on a 45 year old woman. The woman who in this case is a patient underwent PLIF (posterior lumbar inter-body fusion) process. This is a surgical process intended to treat posterior back pain with various injuries occurring secondary to a degenerative disease on a disc, scoliosis or spinal stenosis. When undertaking the PLIF procedure removal of portions on the vertebral spinouts route plus the lamina in order to decompress spinal cord roots and stabilization of vertebral segments. After the PLIF procedure, MS patient is supposed to spend about 3 to 14 days in a hospital to check on their medical stability. In addition, patients may need physical therapy services after the surgical operation as a way to progress ambulation so that they go back to their homes safely.
PATIENT MEDICAL HISTORY
The patient in this case report had undergone the PLIF procedure because of chronic posterior back ache which became worse over the last 3 years. She has a medical history of high blood pressure on a consistent pattern. In 2002 she became diagnosed with multiple sclerosis and insomnia. In addition, the patient has a medical history on L4-L5 injections on lumbar epidural steroids. In 1998 she received T8-10 thoracic laminectomy because of a herniated intervertebral disc. She received services on physical therapy because of a past surgery intended to improve her locomotion functions which returned her to her former level of functioning. The patient since admitted, does not show any signs on MS exacerbation because she suffered from MS.
She was requested to be wearing thoraco-lumbo-rthosis in addition to following restrictions from surgical processes for 9-11 weeks for every surgeon. Example of these restrictions included restraining from hip flexion on a 90 degree, avoid rotation of the lumbar and lifting weights about 7-10 pounds. She was under the following medication on being advice by nursing staff; potassium chloride, Baclofen, Oxycodone, Carvedilol, Calcium and Methylprednisolone.
During her initial functioning levels, she used to complete her daily chores in their family house because she is married. Moving around her home and community she used a wheel walker. She also worked with a NGO as a social worker a position she worked for the last 5 years. This patient lived in a bungalow house with some three fairly stepped cases to enter their house plus a 10 stair case into her home store with railings on both sides. In the last 10 months the patient noted high incidences of inability to complete her daily chores that needed lots of moving around. Occasionally she fell because of weakness in her body leading her to get a house help to assist in most of daily household chores. When she underwent the PLIF process, her desire was to go back to her normal life of working in the house as a wife and continue with her work as a social worker in her community.
The need for first examination was to establish the nature of present impairments and limitations on movements functioning on the patient after the signs of MS and surgery procedures. Towards this end, it is important for an initial examination so that the best physical therapy plan can be used to help the patient with minimal pain and get her to her previous level of functioning. In this examination, it was evident that the patient qualified to be a good candidate to go for a physical therapy service because she was receiving PLIF procedures. In addition, she was medically fit to receive physical therapy services to manage her acute pain. In order, to continue with this exercise she gave verbal and written consent
Upon completion of 24 hours bed rest and lying totally flat after the surgery exercise she received an examination of physical therapy on the second day after surgery. She was alert on all conditions of time, place and any arising situations around her. The patient was a little lethargic because of effects of being on medication. According to the rating scale on the numerical pain rating she recorded 4 out of 10 on the following; right shoulder in supine, her bilateral hip and surgical incision site. The patient also reported an increase in pain on a rate of 2-3 out of 10 whenever she was sitting an edge of plane surface. She denied occurrence of exacerbation as sign of MS though reported she has been weak over last few years. Her bilateral LE dermatome sensations plus proprioception were fit. She did not have hyper or hypo tonicity cases on bilateral LE. Normal limits reported for active range in motion together with passive range of motion; AROM and PROM respectively on siting on an edged surface. She recorded LE strength that was equal or more than 3 out of 5 on testing her muscles manually. The 45 year old woman only required assistance on moderation whenever she needed to roll on her right hand side. Lying on her right side needed moderate assistance of a therapist and bilateral LE help with her head side of the bed on an elevation to 30 degrees. She reported difficulty whenever she attempted to transfer from a sit to stand with noting of pain and fatigue during such attempts.
Upon evaluation the patient recorded a 45 out of 126 score for Functional Independence Measure (FIM). This measure is used to assessing aspects of a patient on physical and cognitive abilities to illustrate level of disability and rate of assist of daily living (ADL). Other tests on bed mobility, her ability to take on body transfers such as sit to stand plus ability on static sitting balance were scheduled for coming session depending on her physical status.
SECOND SESSION CLINICAL IMPRESSION
The patient in this case report recorded little lethargic because of side effects coming from medication. During this time of observation her initial impairments included pain with notable reduced static balance. As a result there was reduced mobility in bed, transfers and engagement in activities requiring movements around the house. Example of disabilities at present, include limitation of not working formally as a social worker and not performing her duties as a spouse as in her past life.
This case therefore qualified to be a scenario of potential success in rehabilitation considering her present impairment conditions and having undergone PLIF procedure. Therefore, the services on physical therapy would be beneficial to get her back to initial functioning levels. She was medically fit with not any recorded exacerbations or complications because of drug taking deeming the rehabilitation process appropriate. Administering acute physical therapy on a frequency of 3-4 days was recommended to improving her current limitations.
During her first physical therapy care session a recording of new signs plus impairments, in contrast, of previous physical therapy examination carried out. She reported difficulty in moving left LE and any attempt she noted increasing fatigue, her fingers became numb and general body ache. The right LE illustrated moderate weakness on a scale of not more than 3 out of 5on flexion of her hips. The patient also reported on scale of 5 she moved her knee on a rate of at least 2 with extension of knee not more than 4 out of 5. Her left LE recorded on hip flexion a 2 out of 5, at least 1 out of 5 for extension of the knee while sitting on edge of her bed ( Snook, 2007). Moderate assistance was needed to help the patient lie on her right side to bring about trunk movement. She was not able to control her sitting balance on her seating on bed edge. She needed maximum assistance for sitting because of complaints of fatigue. During the acute treatment the signs remained and she was kept still under hospitalization
THE INTERVENTION MECHANISM
She received nine 25 to 60 minutes on a session of professional physical therapy treatment twice daily for a period of 6 days. This was deemed to be appropriate to get her back to her initial working and locomotion function. Any modification on the needed treatment by the patient was to be recommended upon progress and medical status of the patient. The concern for the first treatment was to treat her and improve on her mobility that includes mobility on bed, various transfers and negotiations on stair cases in the house. The treatment included other family members on how to handle the patient around the house. Any further new treatment was to depend on the level of pain on the patient and her medical status. This treatment included 40 to 50 stretches on left knee for extensions and LE was undertaken through several paces of flexion. Such exercises and trainings would be intended to cause a decline in tensions of the muscles on patient’s limbs.
The patient made several slow improvements both on her mobility in bed, transfers and her static activities. Her activity tolerance for standing and sitting took now 15 minutes which was an improvement. The therapist education for the family improved safety awareness on how to handle her when carrying out transfers and mobility in bed. Exacerbations signs were the only causing negative effects on her mobility functions. Her care to reach trials ambulation and other training were not to be carried out at this stage since she was not fit medically. In order to, receive increase mobility the patient to continue with the physical therapy treatment for a period of three weeks.
Inpatient treatment progressively gave the patient improvements in her desire to go back to her initial functions. By the end of week one she had recorded a FIM of 60 and 79 by end of second week. Upon full completion of her inpatient treatment she has made strides in improving mobility in bed, static balance, ambulation trials and tolerance towards assistance. A final measurement of her FIM rate was recorded to be at 100 which was a little way below the expected 105 by end of treatment. By this time she was able to ambulate at least 100 feet with use of a wheeler and with little assistance. At the time she was deemed as fit to return home she was not able to carry on negotiation of the stairs in her house. She was proud of gains by time of going home and was hopeful to go back to her social work by end of three months. Her husband agreed to be of help whenever there was any difficulty as she tried to get back to her initial functions.
A lot of patients with MS disease have chronic or acute pain and in most cases PLIF procedure is used as a way to handle other complications in degenerative disc or spinal stenosis (Zdeblick, 2010). Physical trauma can lead to multiple sclerosis exacerbations as the case experienced in this report. Where the patient had not showed any signs of exacerbations however upon completion of PLIF treatment she started showing the symptoms. The patient at initial examination showed only lack of mobility and limitations on her functions. During the acute care new signs came up leading to reduced functional abilities.
It is through undergoing professional physical therapy treatment while still admitted in the hospital she improved on her health status. She was set to go home because the exercises and treatments gained from physical therapy had resulted in improving her functional abilities. On-going home she was to continue with therapy session with assistance from her husband. The hospital and nursing staff recommended use of home physical therapists that will assist in care at home to manage her condition. This report attributes her fast recovery to the physical therapy treatment. There are also other factors that are attributable to her recovery. For example, her age, the timing for seeking medical assistance and other factors such as her desire to get back to functioning as her initial status