Solution

The relevant categories in the brief ICF Core Set for MS (accessed 15 November, 2011) for an ambulation problem in Maya's case include:

• b130 Energy and drive functions
• b152 Emotional functions
• b280 Sensation of pain
• b730 Muscle power functions
• b735 Muscle tone functions
• b760 Control of voluntary movement functions
• b770 Gait pattern functions
• d230 Carrying out daily routine
• d450 Walking
• d455 Moving around
• d640 Doing housework
• d760 Family relationships

Rationale & evidence

The selection of the ICF categories is based on the neuromuscular, musculoskeletal, somatosensory and cognitive & perceptual impairments that contribute to gait parameters (Shumway-Cook et al. 2012, see chapters 14 & 15).

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; ROM = range of motion

Fatigue was not included in the hypotheses because of its complex nature and difficulty to measure different components of fatigue (Bradley et al. 2010). In addition, in a recent Cochrane review exercise therapy was not been found to alleviate fatigue (Rietberg et al. 2011).

Rationale & evidence

The justifications for inclusion of anticipated problems in the problem list were discussed with Maya before placing it in the problem list. They included:

• P4: As Maya estimates her maximal non-stop walk distance to be just over 10m, it is reasonable to believe that she is not able to move around the large rehabilitation centre without a wheelchair without getting excessively fatigued.
• P5: Based on the interview, Maya's husband has raised concerns that Maya’s deteriorated physical capacity and increased fatigue have decreased her social functioning and quality of life (QoL). Persons with MS (pwMS) whose disease is more severe, who receive disability pension or who have children to care for are typically less physically active (Beckermann et al. 2010). As gait, disability, hypertonia of lower limbs and fatigue negatively affect quality of life, treatment with an emphasis on physical conditioning, gait and fatigue should be considered to improve QoL in pwMS (Nogueira et al. 2009).
• P6: Based on the interview, it is apparent that Maya does not receive the health care and social support she requires for maintaining her physical capacity and QoL. For example, as Maya's lower extremities are stiff in the mornings, it is reasonable to believe that her muscle tone is increasing. Because pharmacological treatment is the main treatment for spasticity (Smania et al. 2010), it is important to ensure that Maya knows when to approach her neurologist. Maya does not have adequate assistive devices, she does not receive individual physical therapy sessions or help with housework.
• The hypothesised underlying factors are based on neuromuscular, musculoskeletal, somatosensory and cognitive & perceptual impairments that contribute to gait parameters (Shumway-Cook et al. 2012, ch. 14 & 15).

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; ROM = range of motion; PSCQ = patient-specific complain questionnaire; VAS = Visual Analogue Scale; MSWS-12 = Multiple Sclerosis Walking Scale - 12; 25FWT = 25-foot (7.62m) Walk Test; w/ = with; SF-36 PCS (physical component summary score); SF-36 MCS (mental component summary score); OGA = Observational Gait Analysis; BBS = Berg Balance Scale; MRC-scale = Medical Research Council Scale; MAS = Modified Ashworth Scale.

Rationale & evidence

The relationship between gait parameters and impairments is complex and depends on the extend of the impairments, functional level and compensation capacity of the other systems (Shumway-Cook et al. 2012). The following measurement instruments were chosen to reflect a range of activity & participation and body functions & structure measures:

Activities & participation

• Patient-Specific Complaint Questionnaire (PSCQ) is used to identify and evaluate the extend of functional limitations (Keus et al. 2004). In Maya's case the PSCQ consisted of measuring maximal non-stop walking distance (in meters) outside on flat concrete surface. In addition time (in minutes) was recorded and the Visual Analogue Scale (VAS) was used to assess effort and low back pain.
• Multiple Sclerosis Walking Scale (MSWS)-12 measures self-reported walking difficulties in everyday life (Hobart et al. 2003, Motl et al. 2008, Bladh et al. 2011). The MSWS-12 consists of 12 items scored at a scale of 1-5 with a total sum of 60 points indicating the highest limitation and 12 no limitation.
• 25ft Walking Test (25FWT) at maximal speed from a static start with 1 crutch was used for measuring gait velocity in Maya's habitual walking style. The test perfectly resembles relevant daily life situations such as crossing an intersection (Gijbels et al. 2011).
• 25ft Walking Test (25FWT) at maximal speed from static start (Gijbels et al. 2011) with 2 crutches was used to evaluate gait velocity when Maya has more symmetrical support from crutches (Shumway-Cook et al. 2012).
• SF-36 scale was used to measure various aspects of health-related quality of life (QoL). The scale has been widely used in QoL studies carried out in MS patients (Nogueira et al. 2009). The SF-36 is a generic scale consisting of 8 sub-scales that can be used independently (Dallmeijer et al. 2007). 50 points is considered the norm.

Body functions & structures

• Observational Gait Analysis (OGA): for assessment of disturbed gait pattern functions and kinematic patterns of movements (Shumway-Cook et al. 2012).
• Berg Balance Scale (BBS): for assessment of postural control. In Maya's case the BBS is used for assessment of a hypothesis of an underlying problem in gait and therefore treated as a testing criteria.
• Upright motor control test: for assessment of ankle, knee and hip flexion & extension strength in standing position (Shumway-Cook et al. 2012).
• Joint position & joint motion: for assessment of proprioception (Shumway-Cook et al. 2012).
• Modified Ashworth Scale (MAS) and clonus testing: for assessment of muscle tone and clonus.
• Passive ROM: for assessment of passive range of motion.

Consultation

It was not possible to create a comprehensive examination strategy for the following underlying factors:

• Low self-efficacy: referral to psychologist for consultation.
• Insufficient assistive devices: referral to occupational therapy for consultation.
• Insufficient support from health authorities: referral to rehabilitation social services for consultation.

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; SW = social worker; ROM = range of motion; PSCQ = patient-specific complain questionnaire; VAS = Visual Analogue Scale; MSWS-12 = Multiple Sclerosis Walking Scale - 12; 25FWT = 25-foot (7.62m) Walk Test; w/ = with;  SF-36 PCS (physical component summary score); SF-36 MCS (mental component summary score); OGA = Observational Gait Analysis; BBS = Berg Balance Scale; MRC-scale = Medical Research Council Scale; MAS = Modified Ashworth Scale; R = right; L = left; UMCT = Upright Motor Control Test.

Rationale & evidence

Rationale for hypotheses:

• H1 - H3 are accepted based on the findings in OGA, BBS, upright motor control test and manual muscle testing using the MRC-scale.
• H4 and H6 are refuted based on the findings in joint position & joint motion testing and passive ROM.
• H5 is partly refuted based on the findings in MAS and clonus testing.
• (H7 and H8 A psychologist and occupational therapist were consulted already before examination.)

Rationale for refining the problem list

• P4 Based on the findings in the PSCQ, Maya needs a wheelchair to transfer from place to place in the rehabilitation centre. The problem is removed from the problem list and referred to the occupational therapist.
• P6 Based on the interview and complete examination findings, the need for review of the health care services she requires / receives at this point in time and in the future is apparent. Maya was already referred. The problem is removed from the problem list.

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; ROM = range of motion; PSCQ = patient-specific complain questionnaire; VAS = Visual Analogue Scale; MSWS-12 = Multiple Sclerosis Walking Scale - 12; 25FWT = 25-foot (7.62m) Walk Test; w/ = with; SF-36 PCS (physical component summary score); SF-36 MCS (mental component summary score); OGA = Observational Gait Analysis; BBS = Berg Balance Scale; MRC-scale = Medical Research Council Scale; MAS = Modified Ashworth Scale; R = right; L = left; UMCT = Upright Motor Control Test.

Rationale & evidence

When a goal was set to achieve an improvement, the measure was set to reflect minimal detecable changes. Several reference values for minimal detectable changes specific for persons with MS (pwMS) are available (Paltamaa 2008). When they were not available, the general rule of 20% change was applied (Schwid et al. 2002).

The SF-36 and MSWS-12 are used as a predictive criteria for P5 (Deteriorated physical capacity decreases Maya's quality of life). The reassessment date is set at 3 months with an acknowledgement that reassessment requires that Maya is able to see a PT regularly in her home environment. Regardless, the measure functions as a reference value for future inpatient rehabilitation periods.

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; ROM = range of motion; PSCQ = patient-specific complain questionnaire; VAS = Visual Analogue Scale; MSWS-12 = Multiple Sclerosis Walking Scale - 12; 25FWT = 25-foot (7.62m) Walk Test; w/ = with; SF-36 PCS (physical component summary score); SF-36 MCS (mental component summary score); OGA = Observational Gait Analysis; BBS = Berg Balance Scale; MRC-scale = Medical Research Council Scale; MAS = Modified Ashworth Scale; R = right; L = left; UMCT = Upright Motor Control Test.

As Maya does not have individualised physical therapy at her home environment, training plan is made to encourage Maya continue being physically active after the rehabilitation period. The aim of the plan is to maintain / improve her physical capacity (see P5) and to ensure that Maya and her husband have adequate knowledge of MS and understand the consequences:

• Aerobic exercise (e.g. walking, cross-trainer, swimming): 3 x week, 15-30 minutes as tolerated, intensity as tolerated
• Muscle strength: core stability, hip adbuctors, knee extension, back extension 2-3 x week, 2-3 x 12 -15 rep as tolerated, intensity as tolerated (body weight or ankle weights)
• Balance exercises: integrate into ADLs, daily as tolerated.
• Separate information sessions for Maya and her husband and the whole family.

Rationale & evidence

• Task- and context-specific motor learning principles were adapted in the interventions (Morris et al. 2002, Pearson et al. 2004; Shumway-Cook et al. 2012).
• Problem - specific activities and tasks that provide a challenge for the multiple systems involved in walking were included. This approach seems to be more effective that exercises targeting a single system. The activities and tasks were systematically progressed from easy to challenging (Shumway-Cook et al. 2012).
• Try-out periods of dynamic ankle supports were included with the aim to assist ankle dorsiflexion and to prevent knee hyperextension (NICE 2003, Shumway-Cook et al. 2012).
• Core stability exercises were included for Maya to learn strategies to control her trunk when walking (Shumway-Cook et al. 2012).
• Prevention plan: A comprehensive plan was created in an attempt to guide Maya in remaining physically active. Intensive exercise programs do not influence the progression of MS or cause exacerbations (Beckerman et al. 2010).

Solution

Abbreviations used in the Canvas: E = existing (problem); LE = lower extremity; NPIP = non-patient identified problem; OT = occupational therapist; ROM = range of motion; PSCQ = patient-specific complain questionnaire; VAS = Visual Analogue Scale; MSWS-12 = Multiple Sclerosis Walking Scale - 12; 25FWT = 25-foot (7.62m) Walk Test; w/ = with; SF-36 PCS (physical component summary score); SF-36 MCS (mental component summary score); OGA = Observational Gait Analysis; BBS = Berg Balance Scale; MRC-scale = Medical Research Council Scale; MAS = Modified Ashworth Scale; R = right; L = left; UMCT = Upright Motor Control Test.

At the end of the rehabilitation period it was clear that Maya was going to get the dynamic ankle support. The reassessment was done with Maya wearing the dynamic ankle support to reflect her functional capacity.

Reassessment of existing problems

Have the goals been met? PSCQ - VAS yes; distance yes; 25FWT - 1 crutch: no; 25FWT - 2 crutches: yes.

• PSCQ and 25FWT with two crutches: Measurements indicate that testing criteria have been met. Based on the measurements, the credibility of the hypotheses seem to be acceptable.
• 25FWT 1 crutch:
  - Do measurements indicate if the testing criteria have been met? yes
  - Is each hypothesis appropriate and are the testing criteria correct for that hypothesis? yes
  - No  testing criteria was considered to need revision.

Rationale & evidence

The quality of Maya's gait improved considerably during the 17-days. Yet, good quality gait was automated and required a lot of concentration. Maya began to prefer walking with two crutches and this may reflect on the faster walking speed with two crutches in the 25FWT.