Multiple Sclerosis Case study & Use of DMT in West Berkshire

MS Specialist MasterClass 3, 2018

Case Study

Patient B.T., 32 year, female who presented with leg weakness and tingling in February 2018. She had a past history of fracture left tibia in November 2017.

MRI Spine and brain showed transverse myelitis at C7 spinal cord and multiple plaques in the brain. CSF lumbar puncture showed increased proteins and presence of oligo-clonal bands. Relapsing Remitting Multiple Sclerosis was diagnosed.
Neurologist and MS Clinical Nurse Specialist started Tecfidera (Dimethyl Fumerate) 240 mg BD PO in early April. She had nausea & intermittent rashes as expected side effects.

She was transferred to Neuro Rehab Unit in late April 2018.

On examination, she was a tall, well nourished, young caucasian lady, with dark brown hair and eyes. She was alert, communicative, interactive, slightly anxious but appropriate in mood. She had normal vision and eye movements. There was no inter-nuclear ophthalmoplegia. Her speech was normal and has normal cognition.

Upper limb tone, power, coordination, sensation and reflexes were all normal.
She struggle to sit upright without support of the arms on the bed and tends to fall backward. There was reduced truck control.

She had retention of urine in the bladder and needs an indwelling urinary catheter. She had 2 attempts at trial without catheter but failed. She was continent with bowel with some constipation. She refuses laxatives due to nausea (side effect from Tecfidera), and prefers to pass motion in the pads, lying on the bed.

Lower limbs were stiff with high muscle tone but weak in power 3-4/5 and coordination, worse on the right. She has exaggerated tendon reflexes and bilateral extensor plantar responses.
Spasticity was “modified Ashworth scale 3” in the right hamstrings and gastrocnemius + soleus, “ modified Ashworth scale 2” in left gastrocnemius.
On standing, she developed bilateral ankle clonus and sudden flexion of the right knee, requiring a physiotherapist to place the right foot down when using a rotunda to transfer from bed to chair. She also struggled with transfers using a sliding board slowly, supporting the body with both hands on the chair.

Impairments:

Spastic paraparesis (spasticity worse on the right), urinary retention, constipation, reduced trunk control, altered sensation in lower limbs and reduced range of movements both ankles (foot drop).

Activity & participation:

Sliding board transfers +1person (p), self propelled wheel chair for indoors and short distances, electric wheelchair for longer distances, personal care +1p. Stand +2p to + 3p. Fatigue, loss of motivation to participate in physical activities and to go into hydro-therapy pool. Unable to return to father’s house or climb stairs. She needs a wheelchair friendly independent living flat, preferably ground floor.

Rehabilitation Goals:

(1) Independent low pivot transfers, (2) to Self propel wheel chair to gym, (3) Stand with aid, to assist lower half dressing with +1 p, (4) Manage fatigue, (5) Car transfers with +1p, (6) Make hot drink & snack standing with set up, (7) Participate in leisure & therapy group activities.

Treatment:

Vitamin D 4000 IU OD PO (Low Vit D 34 nmol/L), Botulinum toxin injections, treatment of urinary infections (Nitrofurantoin) and bladder spasms (Solifenacin).

Discharge plan:

Rehousing, Community Care and Community based Neuro-rehabilitation. DMT Tecfidera Rx monitoring buy Neurologist & MS CNS.

• West Berkshire total population: 500,000
• Total number of MS patients: 1200-1300
• MS patients/100,000 pop: 240-260
• Number of MS patients on DMTs: 211 (17 %)
• Interferon 74 (35%); Tecfedera 41 (19%); Copaxone 39 (18%);
• Fingolimod 35 (17%); Tysabri 13 (6%); Lemtrada 6 (3%); Aubagio 3 (1%).