Rehabilitation of a Patient Severely Involved with Multiple Sclerosis JULIE POUNDERS, B.S.

This case study presents a young woman who was admitted to our facility in an emaciated physical condition. She had multiple pressure sores and severe contractures about the neck, trunk, and lower extremities, necessitating depend­ ence in all care. Slow but consistent progress was noted throughout a four-month aggressive rehabilitation program. The various treatment approaches and resulting functional gains are detailed.

The patient, twenty-four years old and formerly a clerk-typist, had become bedbound within one year following a diagnosis of multiple sclerosis. She had been discharged from a general hospital to the care of her mother as an alternative to nursing home placement; however, when her mother became ill and could not care for her properly, she was hospitalized a second time. Poor bed position­ ing at home and the onset of severe flexor spasticity in her hips and knees had caused the development of large decubitus ulcers on her sacrum, both trochanters, both ischial areas, medial aspects of both knees, and lateral aspects of both ankles. Her second hospital course had been marked by severe respiratory difficulties and urinary tract infections. Further complications were severe weakness of the upper extremities with

Mrs. Pounders was staff physical therapist at New York State Rehabilitation and Research Hospital (now the Helen Hayes Hospital) in West Haverstraw, New York, when this paper was written. She is currently employed by the University of Alabama Hospitals and Clinics and is physical therapist and clinical supervisor at the Cerebral Palsy Center of Greater Birmingham, 2430 11th Avenue, North, Birmingham, AL 35234.

Volume 55 / Number 6, June 1975

intention tremors, severe extensor spasticity of the neck and trunk, severe flexor spasticity of the lower extremities, blindness in the right eye and impaired vision in the left, malnutrition, and severe hypochromic anemia. The patient's pressure sores had been treated with daily saline irrigation and application of vaseline-impregnated gauze, and occasional debridement had been done. The pressure sores, however, had shown no response to treatment. Bedside physical therapy had consisted of bronchial drainage and passive range-of-motion exercises. INITIAL EVALUATION The patient was admitted to our facility, totally dependent, two years postonset of multiple sclerosis. Within several days after admission, her medical condition had stabilized, and the physical therapy evaluation and treat­ ment program were initiated. Evaluation revealed that upper extremity strength was fair, with endurance lasting for only two or three repetitions of movement. Moderate intention tremor was noted bilater­ ally. The patient held her neck in a position of extreme cervical lordosis, and neck motions 611

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ities, to accomplish these objectives, along with progressively longer wheelchair sitting, were incorporated into a functional training program in conjunction with occupational therapy. Plastic surgery for the decubitus ulcers was not considered because of the patient's pre­ carious medical condition. Following daily Hubbard tank cleansing and mechanical de­ bridement, the ulcers were further debrided by the physician and were medicated as necessary. Bed positioning by hourly side-to-side turn­ ing on a hard mattress covered with 2.5-centi­ meter foam rubber minimized pressure at all bony prominences. Pillows were used to posi­ Fig. 1. Decubitus ulcers of left hip area and hip tion the patient's neck to encourage neck and knee flexion contractures at time of flexion, to wedge the knees into extension, and admission. to maintain the hips in abduction. Sitting in a wheelchair was not believed to be were severely limited in all directions. Neck detrimental to pressure sore healing if pressure flexor muscles showed only a trace of strength. were relieved every thirty minutes by the No active anterior trunk muscles could be patient or an attendant and if the patient were palpated, and the patient's back was maintained positioned properly in the chair. Daily improve­ in severe lumbar lordosis. No voluntary motion ment in tolerance for sitting in a wheelchair could be demonstrated in the lower extremities. depended upon the cooperative effort of the Spasticity of the hip flexor, hip adductor, and physical therapy and nursing staffs. A foam seat knee flexor muscles was severe. Forty-degree cushion was devised with cutout sections large hip flexion contractures and 100-degree knee enough to accommodate the sacral and ischial flexion contractures were present bilaterally. sores. The patient also required a back cushion Superficial sensation was intact in the pa­ with a cutout sacral area and, initially, addi­ tient's upper extremities and trunk, but dimin­ tional padding in the lumbar area to provide ished distally until absent in the ankles and comfort and to accommodate her excessive toes. Proprioception was intact, except for lordosis. The lumbar padding was removed some diminution in the ankles and toes. when the lumbar muscles were stretched and The patient's initial vital capacity measured comfort was attained. Also, initially, the pa­ 485 cubic centimeters, or 15 percent of her tient required a wheelchair back extension predicted capacity of 3,200 cubic centimeters. when she reclined in the chair. Problems Large, infected pressure sores were present in necessitating the extension were lack of head the sacral area, over both trochanters and control, discomfort from cervical and lumbar ischia, on the medial aspects of both knees, extensor muscle tightness, soreness around the lateral aspects of both ankles, and the medial decubiti, and the complaint of dizziness and tibial area of the right leg (Fig. 1). dyspnea in the sitting position. Upper extremity strengthening exercises OBJECTIVES AND TREATMENT REGIMEN progressed from active-assistive exercises using functional patterns to active repetitive move­ The objectives of the treatment program ments, to manually resisted exercises, and were to aid healing of the decubitus ulcers by finally to the DeLorme method of progressive daily treatment in the Hubbard tank and by resistive exercises. Dumbbells and pulleys were proper bed and wheelchair positioning and to used in functional patterns, as was a specially improve physical function by daily upper designed apparatus for resisting shoulder de­ extremity strengthening exercises, breathing pression (Fig. 2). All exercises were performed exercises, passive exercises, and positioning of to the point of fatigue with frequent rests. The lower extremities, neck, and trunk. The activ­ intention tremors, which were moderate upon

TREATMENT RESULTS

Fig. 2. The "depression exerciser" provides stability to allow the patient to lean forward and perform bilateral progressive resistive exer­ cises. The lever arm can be changed as well as the height of the apparatus.

admission, decreased with increased muscle control and were never a functional problem. Because the weakness and poor endurance were believed to have resulted not only from the disease but from disuse atrophy and a resultant decrease in vital capacity, a breathing program was instituted. The patient was trained in the correct breathing pattern and received manual resistive breathing exercises. Daily positioning and passive range-ofmotion exercises of the patient's lower extrem­ ities prevented further tightness before and after bilateral distal hamstring tenotomies were performed. Following surgery, hamstring mus­ cle length was also maintained and improved by progressive molded plastic posterior knee splints, fashioned by the orthotist and occupa­ tional therapist. The surgery and positioning program were sufficiently successful to allow the patient to wear the splints only in bed. She was able to sit in the wheelchair with her legs maintained in proper position. As the hip flexion contractures gradually lessened, lumbar lordosis decreased. Sitting in a wheelchair and performing active forward trunk flexion discouraged lordosis. The lack of head control, however, was a major deterrent to the patient's function. When roentgenogram studies showed no bony changes, a program of passive manual stretching, positioning with pillows and sandbags, and muscle reeducation was started. A device was designed and made by the Volume 55 / Number 6, June 1975

Initially, the patient reacted to the daily Hubbard tank treatments with complaints of stomach upsets and dizziness, and she experi­ enced dyspnea and decreased tolerance for exercise. Following a week's episode of pyloric spasms, necessitating intravenous and nasogas­ tric tubes, the tank treatments were reduced to two per week. The patient no longer expressed anxiety or excessive fatigue and tolerated all phases of the treatment program well. During the four-month period, sitting toler­ ance in a wheelchair slowly increased from one hour a day at a 45-degree sitting angle to eight hours a day alternating between 80 and 90 degrees without head support. All pressure sores except the trochanteric and left ischial sores completely healed within this period (Fig. 4)At the time of discharge, when the patient was sitting in the wheelchair eight hours daily,

Fig. 3. The head support can be adjusted to tilt up or down, and sideways. The remaining adjustments allow the apparatus to move up or down, forward or back. 613

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hospital's special apparatus department to stretch the extensor muscles and support the patient's neck during sitting. The device, which could be adjusted in any plane of movement, contributed significantly to progressive passive neck stretching and head control (Fig. 3).

SUMMARY

Fig. 4. Left hip area three months after admission. her vital capacity had increased to 800 cubic centimeters, or 25 percent of her predicted capacity. As general strength and neck move­ ments improved, she was able to pull her head away from the wheelchair head support and perform activities unsupported for periods of time up to one hour. This young lady entered our facility com­ pletely dependent for all activities of self-care. As strength, endurance, and joint mobility improved through the described techniques, she became able to groom and dress her upper body, feed herself independently, turn from side to side in bed, perform an assisted depression transfer between wheelchair and bed, assume responsibility for relieving pressure

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Physical therapists must be content to treat the symptoms of multiple sclerosis, and, at the same time, must understand that, because of the presence of remissions and exacerbations, treatment results are difficult to assess. Never­ theless, patients with multiple sclerosis who participate in a functional exercise program may progress far better than those confined to bed. "Those on a total rehabilitation program maintain a high level of well-being, experience fewer exacerbations, and are able to maintain their functional level." 1 The young lady discussed in this report possessed a realistic attitude toward her disabil­ ity and functional goals. Participating in a rehabilitation program guided by her physical and psychological needs, she improved beyond her expectations. Although her poor eyesight has prohibited her returning to her former occupation, she has again become a productive family member, assisting with her own care as well as helping to manage the home. REFERENCES

1. Aides JH: Rehabilitation of multiple sclerosis patients. J Rehabil 33:10-12, 1967.

PHYSICAL THERAPY

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in the sitting position, and manage the wheel­ chair independently.

Rehabilitation of a patient severely involved with multiple sclerosis.

This case study presents a young woman who was admitted to our facility in an emaciated physical condition. She had multiple pressure sores and severe...
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