Multiple sclerosis (MS) is the most common progressive neurologic disease of young adults, affecting 350,000 to 400,000 people in the U.S. 1 The disease most commonly presents with intermittent relapses and evolves to a progressive form. Common symptoms include weakness, sensory loss, vision disturbances, ataxia, bladder dysfunction, cognitive deficits, and fatigue. A thoughtful multidisciplinary approach is essential for patients with MS who live with an unpredictable disease, numerous secondary symptoms, and the fear of debilitating progression. The goal is to maintain good quality of life (QOL) for patients with MS.
This article responds to the issues presented by a young patient recently released from active-duty military service and illustrate the power of a team
approach to managing the care of patients with MS. The 3 sections are written from the perspectives of (1) neurologists and physiatrists; (2) nurse practitioners; and (3) psychologists and also represent contributions of each discipline toward the goal of maintaining QOL for patients with MS. Although these health care specialists are highlighted, many more were involved in the care of this patient and are not included due to space constraints.
Case Presentation
William is a 31-year-old African American man who began experiencing headaches, occasional imbalance, periods of confusion, and mental fogginess following discharge from active duty 5 years ago. William had been deployed to Afghanistan and was exposed to at least 1 improvised explosive device blast while there. He did not disclose to army physicians a 24-hour loss of vision in his right eye while driving a tactical vehicle in Kandahar, Afghanistan. The patient thought his vision changes were caused by stress and worried that he would be removed from patrol duties if he reported the problem. At the time of his discharge, William was diagnosed with mild traumatic brain injury from blast exposure.
After discharge, William sought care in the private sector but felt providers assumed all his symptoms were the result of depression or posttraumatic stress disorder. He began noticing problems at his new job: missing deadlines, forgetting conversations, and having difficulty making decisions. William’s gait became clumsy, and he occasionally tripped and ran into walls. He worried that his supervisor and colleagues would discover his problems, so he quit his job. William knew something was wrong and wanted a provider who would understand him. He decided to take advantage of the VA health care system and its promise of care for Operation Enduring Freedom/Operation Iraqi Freedom veterans. He had an initial evaluation with his primary care Patient Aligned Care Team (PACT), which noted deficits on his neurologic examination and referred him to the neurology clinic affiliated with the MS Centers of Excellence (MSCoE). 2
William’s neurologic examination was significant for psychomotor slowing, memory loss, cerebellar ataxia, and lower extremity spasticity. Magnetic resonance imaging (MRI) of the brain and spinal cord were obtained as recommended by the Consortium of MS Centers guidelines. 3 The MRI showed 12 high-frequency T2 lesions in the periventricular regions bilaterally and cerebellum. One lesion was gadolinium enhanced. Two additional high T2 lesions were noted in the upper cervical spinal cord. After ruling out mimics, William was diagnosed with relapsing remitting MS, based on McDonald Criteria. 4 His Expanded Disability Status score was 3.0, and deficits were documented in the pyramidal, cerebellar, and cerebral functional systems. 5 William’s history and symptoms, blood, and cerebrospinal fluid studies were consistent with the typical pattern of relapses and remissions with neurologic symptoms separated in space and time.