Neuroscience/Case of the block

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Paulette Lynch

In 1987, I had a great life. A good job as Faculty at Fanshawe College, a graduate degree, a supportive husband, and no financial worries. We had no kids, but had many social contacts, and I held positions on three community boards. I walked, cycled, golfed and skied. I had a passport to travel the world...and I did.

During that summer, there were record heat waves. I started feeling odd tingling sensations in my limbs, and my handwriting looked somewhat shaky. I was not sure what was happening: the heat perhaps? I felt so tired; I couldn?t complete a full day?s work without taking cat-naps on my desk. After a while, I felt somewhat better, but my handwriting still looked a bit careless. Then one day, I had a major case of double-vision. I was driving home in the rain from teaching an evening class out-of-town, and totally scared myself. I was seeing double the number of oncoming headlights and I couldn?t distinguish the edges of the road. I called my physician for an appointment.

She did peculiar tests on me - made me tap by hands together, repeatedly touch my nose and her finger, had me stand with my arms in front of me...Then she said "I am not sure what?s happening here. I?ll arrange for a consultation in neurology". It took several months but I was finally seen in a London hospital, and went on to take several tests. By then, I was feeling much better. No more tingling or double-vision. The neurologist said: "On the basis of your tests, we are reasonably sure that you have MS". I was not sure what that meant for me. So he gave me a bundle of brochures.

Sheet 1 of additional information on Paulette - distributed November 17 Paulette has returned to your office after having read brochures given to her. She has many questions, including "Will all the things I read (loss of balance, lack of coordination, memory impairment, fatigue, incontinence, speech problems, etc) happen to me? I have been practising many sports, and walking regularly: what can I continue to do? Will it help if I continue? Or can it be harmful? What about having children? Would I pass on the disease to them? Would I be able to look after them?"

How would you approach the issue of prognosis with Paulette? What are the implications for activities of daily living, driving and work? What is the role and approach of a family physician in caring for an MS patient?

How are ongoing checks of neuromuscular and musculoskeletal function performed?

What treatment options are available for MS in terms of affecting disease progression?

What treatment options are available for common symptoms in MS such as fatigue, painful spasms, neuropathic pain, bladder dysfunction?

Sheet 2 of additional information on Paulette - distributed November 24

You don?t hear from Paulette for a year. Then she makes another appointment with you following an exacerbation of MS. She takes up her story:

"I began to walk like a drunk. The tingling in my limbs returned; I had to consciously will my legs to walk upstairs. I couldn?t even cut my meat in a restaurant or put on earrings. I started using a cane which, although I was terribly self-conscious about using, helped me balance as I walked. But, strangely, my left foot kept forgetting to come along for the ride. The rest of ?89 saw me waiting for a remission like I had in '88. But MS had a mind of its own. It was in ?91 that I heard the phrase 'chronic progressive'".

"My lifestyle is quite different now. No job, on long-term disability. Because I had been employed less than 10 years, I lost my supplemental health insurance. I have to pay for medications, for dental care, etc. A mortgage again, since I needed to have a house with no stairs and with wider doorways. My walking is done with Harley the scooter; even overnight travel is a hassle requiring all the accoutrements of a baby. My Honda is replaced with a para transit card. Travelling is difficult: on my last trip, the Air Canada employee did not know that modern scooters are equipped with gel-cell batteries, and wanted to drain mine...On my return flight, the airline was insisting that I sign a form absolving them of any liability should my scooter be lost or damaged."

"I noticed that I no longer get phone reminders that I am due for a Pap test: perhaps the tests are not needed in MS patients? The last time I was sent for a consultation in ophthalmology, the staff was quite upset because I was not able to transfer independently from my scooter to the examination chair. As one assistant said, "I will not risk hurting my back by transferring you. Why did the MS clinic not send you to a place that has proper equipment for handicapped patients?" But I have yet to see a clinic or office that is equipped with lift of transfer boards/discs, not even the MS clinic. It must be why physicians no longer examine me: they only ask me about my symptoms. I don?t always see a neurologist either, even though I am more disabled now than ever before. I am often only seen by a nurse practitioner, for a quick questionnaire."

"Even my marriage has been bruised. Most of my former friends have backed away, since I can no longer participate in the activities that we used to share. I wonder: who will help me manage my affairs? Who will take my best interest at heart if I become too disabled to make my own decisions or to be understood? Someone asked me if I had signed a Power of Attorney??"

Paulette is asking if new treatments are on the horizon. At her last visit in neurology, she was told that chronic progressive MS is a different disease than the relapsing-remitting form and that, for that reason, medications that help in one form may not help in the other. She does not understand why that is, and would like some explanations.

She heard on the news that two manufacturers, both producing what seemed to her the same medication - called interferon- were arguing that their product were better than the other. She wonders what is the difference between the two products? She has also read that marijuana could be prescribed for MS. She wonders if this would help her or hurt her?

Remember that this is a 3-week case and that, as a group, you can plan your self-learning and discussions for the three PCL session. Your tutor will provide you with additional information. Each group will need to set objectives for the following week once you get the sheet of information from your tutor!

Initial PCL Objectives for November 17

  1. Bring your PCL Guide to the first session and make sure that, as a group, you do the following:
         * Agree what your process will be for each PCL session: research, discussion, objective-setting, summarizing.
         * What will be your plan if (when) you run out of discussion ideas from the COB case?
         * Discuss and agree how Peer Evaluation will occur.
  2. Read the description of how Paulette (remembers how she) received her diagnosis. Discuss how you would do it.
  3. Review the (patho)physiological basis for Paulette's symptoms and physical findings. For example, which nerve tract/column is affected to produce spasticity, double vision etc...with respect to clinical presentation of multiple sclerosis.
  4. Discuss your understanding of etiology, risk, epidemiology, testing of multiple sclerosis.