The neurologist gave William some context to the diagnosis. He noted the changing epidemiology of the disease and that African Americans are considered a highrisk group for rapid progression of MS symptoms. 6-8 A progress note and MS Assessment Tool were completed in the Computerized Patient Record System (CPRS)—an annual requirement recommended by the Multiple Sclerosis System of Care Procedures .9
Symptom Management
All FDA-approved MS disease-modifying therapies (DMT) are available within the VA MSCoE network. After a discussion of risks and benefits with William, the neurologist recommended 2 options for therapy. One option was more aggressive and had the greatest efficacy in a randomized controlled trial, yet a higher risk for adverse events (AEs). The other option had modest efficacy and favorable long-term safety data. After further discussion with his neurologist, William indicated he wanted to avoid risks and preferred medication with a long track record for success and safety. He selected an injectable DMT.
William returned to the clinic 3 months later and reported no new or worsening neurologic symptoms and stated that he was “fine.” However, in a review of his MS symptoms, the neurologist discovered gait ataxia, bladder urgency, and constipation. On further questioning, William admitted to experiencing excessive fatigue, an inability to go to or stay asleep, and difficulty in finishing tasks. William also indicated that he had forgotten to take
his DMT as prescribed, had a fear of injecting himself, and had painful injection site reactions. The neurologist referred him for a bladder ultrasound and for urinalysis and urine cultures, as well as for more extensive cognitive testing with a neuropsychologist and for gait assessment with the physiatrist.
William reported 2 recent falls to the physiatrist, both occurring while walking on his lawn to get the mail, neither resulting in significant injury. He reported using walls and furniture to maintain balance at home. Although he continued to insist that he was fine, further questioning revealed that he at times avoided leaving home due to a fear of falling.
A focused physical examination consisting of an assessment of lower limb muscular strength, coordination, sensation, and spasticity helped identify issues that were causing his impaired gait. Additionally, the impact of changes in vision, cognition, and fatigue were explored, because they also contributed to falls and impacted use of mobility assistive devices.
William had normal strength except for mild weakness in his left ankle dorsiflexors, intact sensation, impaired heel-to-shin performance, and minimal resistance of his hip adductors. A wide base of support, short stride length, and a slow cadence characterized his gait. His average of two 25-foot walk tests was 15 seconds, and by the end of his second trial, he had mild foot drop.
Impairments in gait are typically multifactorial, so treatment plans often consider multiple issues. Because William was able to use a wide base of support to maintain his balance and quality of gait, it did not seem that spasticity was impairing his function. Therefore, an oral spasticity agent was not indicated, although a stretching program was started to prevent potential future complications related to spasticity.