Sofiya Prilik, MD, and Francesca Toone, NP.
PHOTO: KARSTEN MORAN
When immunological complications reduced a high-functioning patient with multiple sclerosis (MS) to a state of severe disability, rehabilitation medicine was key in quickly returning the patient’s full function after treatment.
Initial Treatment
In May 2017, a 44-year-old fully independent male patient with a history of MS presented with worsening weakness in all extremities and pronounced left-side weakness. A brain MRI revealed a right frontal lobe lesion believed to be progressive multifocal leukoencephalopathy (PML), potentially related to the patient’s treatment.
Following admission, with his condition stabilizing, the patient received a physiatry consult from Sofiya Prilik, MD, clinical instructor of rehabilitation medicine. In June, he was transferred to Rusk Rehabilitation for acute inpatient rehabilitation. Within a few days, however, the patient’s left hemiplegia and left hemineglect began to worsen, greatly affecting his balance and mobility. Depressed mood and anxiety further limited his engagement with therapy.
A repeat MRI showed a progression of the PML-like lesions, with associated mass effect and development of an 8 mm left midline shift. The patient was transferred back to the neurology unit, where physicians diagnosed him with immune reconstitution inflammatory syndrome (IRIS), a condition in which the immune system creates a significant inflammatory response in the context of immunosuppression. Treatment with high-dose methylprednisolone eventually succeeded in decreasing his midline shift.
Intensive Rehabilitation
His immunological complications under control, in mid-June the patient was transferred back to acute rehabilitation. Due to the presence of viral pneumonia and parainfluenza, he was admitted to a specialized cardiopulmonary rehabilitation unit with isolation capabilities.
“This patient was very functional at baseline, but he was now quite deconditioned and still suffered from significant left-sided weakness and confusion,” says Dr. Prilik. “Fortunately, we were able to start him right away on intensive therapy.”
The Rusk team’s rehabilitation care plan included the following.
Physical Therapy
The patient had significant functional deficits due to decreased trunk balance, left-sided weakness, left apraxia, and hemineglect. Physical therapists began with range-of-motion exercises, gentle progressive strengthening techniques, and balance and coordination exercises to provide neuromuscular reeducation. As the patient progressed, he tolerated sitting with minimal support, transferring out of bed, and standing. After one week, he could stand in parallel bars with bilateral arm support and perform squat transfers with moderate assistance. Over the next few weeks, he worked on gait stability, ambulation with and without assistive devices, and using stairs. At discharge, the patient could walk 200 feet unaided and go up and down 10 stairs without a cane.
Occupational Therapy
ADL retraining began with coordinating muscle movements in the left hand and arm. Range-of-motion and flexibility training were employed to prevent contractures and facilitate progress with everyday functional activities. Due to the patient’s perceptual deficits, occupational therapists introduced vision exercises and awareness training as he engaged in daily tasks. About 10 days after admission, the patient could shave himself while in a wheelchair, but still needed verbal cues to integrate his left arm. He was soon able to engage in simple meal preparation, and perform simulated laundry and shopping activities. Near the end of his stay, therapy included community excursions, such as a trip to a nearby grocery store, and neuromuscular reeducation for fine motor tasks such as writing and typing.
Speech Therapy
Since the patient worked as a computer programmer, much of his speech therapy was tailored to computer use. Though fluent in English prior to illness onset, the bilingual patient also presented with word retrieval and processing difficulties, further complicated by attention impairment. Initially, he required significant cueing to self-check for accuracy, particularly for information on the left side. As therapy progressed, he sustained attention through complex multimedia tasks and error self-correction. Speech therapists also worked with him on reasoning, problem-solving, and verbal fluency, cultivating additional attention strategies with a rehabilitation notebook so he could eventually return to work.
Psychotherapy
Although the patient displayed a high degree of positive treatment motivation and compliance, he struggled early on with anxiety, depression, and sleep disturbance, issues that became a barrier to full participation in therapy. To overcome these barriers, an inpatient psychologist provided the patient with cognitive/behavioral strategies for anxiety reduction and mood/sleep management. The psychologist also helped the patient stay focused on short-term goals during acute rehabilitation while using a problem-solving approach to identify, specify, and organize longer-term goals. As the patient became more adept at using new coping strategies and skills, his ability to integrate, assimilate, and accommodate therapeutic interventions appeared to flourish.
The patient received several other services during acute rehabilitation, including psychological support to address depression and anxiety related to function loss. Toward the end of his hospitalization, a social worker arranged home care and other therapy services for safe discharge, and a recreation therapist helped him begin to reintegrate with his colleagues by helping him respond to work emails.
Outcome
After four weeks at Rusk, the patient was discharged home. According to Dr. Prilik, the extent and speed of his recovery were remarkable. “This patient, who previously couldn’t get out of bed, walked out of the rehabilitation unit and eventually went back to work as a computer programmer,” she notes.
Dr. Prilik ascribes his recovery to several factors. “He was extremely motivated, with strong family support,” she says. “In addition, he had access to every discipline he needed—a stellar team of physical, occupational, and speech therapists, plus a medical team proactive in finding the best solutions for the particular problems in this rare case.”
