Chauncy Eakins
Debra Brathwaite*
Adrian Cristian
19: Multiple Sclerosis
PATIENT CARE
GOALS
Provide patient care that is compassionate, appropriate, and effective for the treatment of a patient with multiple sclerosis (MS) and the promotion of health.
OBJECTIVES
1. Describe the key components of the assessment of the patient with MS.
2. Assess the impairments, activity limitations, and participation restrictions associated with MS.
3. Describe the psychosocial, vocational, and educational aspects of MS.
4. Formulate the key components of a rehabilitation treatment plan for the patient with MS.
MEDICAL HISTORY
History of Present Illness
A thorough and comprehensive documentation of the history of present illness will provide the clinician with valuable information to make a diagnosis of MS and determine associated impairments. Attacks or exacerbations of MS are characterized by symptoms that mirror central nervous system (CNS) involvement. The sine qua non of MS is that symptomatic episodes are “separated in time and space”—that is, episodes occur months or years apart and affect different neuroanatomic locations. As an example, a patient may present with paresthesias of a hand that resolve, followed a few months later by weakness in a leg or visual disturbances. In addition, the duration of the attack should be longer than 24 hours. Presentation of MS often varies among patients. Some patients have a predominance of cognitive changes, while others present with prominent ataxia, hemiparesis or paraparesis, depression, or visual symptoms. Additionally, it is important to recognize that the progression of physical and cognitive disability in MS may occur in the absence of clinical exacerbations (1). The diagnosis of MS is challenging due to its diverse presentation. Symptoms of disorders such as cerebrovascular disorders, tumors of the CNS, myelopathy, spinal cord injury, peripheral neuropathy, collagen vascular disease, and neurodegenerative disorders can mimic those of MS, making the diagnosis difficult to establish. However, the contrary also exists. Trojano reported that 5% to 10% of individuals are misdiagnosed with MS. Diseases that can be mistaken for MS include those of inflammatory, metabolic, genetic, infectious, neoplastic, and spinal origin (2).
Past Medical and Surgical History
These include spinal surgery and dates, as well as ophthalmologic procedures.
Allergies and Medications
These should be reviewed.
Family, Social, and Functional Histories
It is important to obtain a family history since an increased incidence of MS among the offspring of individuals with MS has been reported (3). The location where the patient spent the first 15 years of his or her life is valuable information since migration studies indicate that the likelihood of developing the disease depends on where a person spent the first 15 years of life (3). These data suggest that either a causative factor was acquired in the more temperate latitudes or a protective factor was acquired in the less temperate climates. Smoking, alcohol, and drug usage are important. Work history, travel history, home environment, family support, and level of independence with regard to self-care and ambulation should be evaluated.
Review of Systems
MS is a disease that can lead to focal as well as diffuse symptomatology; therefore, the clinician should rely on a comprehensive review of symptoms which can uncover related problems that the patient might have otherwise overlooked or thought insignificant.
1. General: Weakness, fatigue, heat intolerance.
2. Cognitive dysfunction: Memory loss, impaired attention, difficulties in problem solving, slowed information processing.
3. HEENT: Facial weakness resembling Bell palsy not associated with ipsilateral loss of taste sensation or retroauricular pain. Eyes: Decreased visual acuity, decreased color perception, periorbital pain aggravated by movement, blurry vision, and diplopia (4).
4. Cardiovascular: Autonomic alterations might relate to clinical signs such as orthostatic intolerance (5).
5. Gastrointestinal: Constipation occurs in greater than 30% of patients with MS. Fecal urgency or bowel incontinence is less common (4).
6. Genitourinary: Urinary frequency, urgency, nocturia, and uncontrolled bladder emptying. This can be due to detrusor hyperreflexia secondary to impairment of suprasegmental inhibition (4).
7. Neuromuscular: Weakness of the limbs, gait disturbance, or painful muscle spasms associated with spasticity.
8. Sexuality: Decreased libido, impaired genital sensation, impotence in men, and diminished vaginal lubrication or adductor spasms in women (4).
9. Neurological: Diplopia, internuclear ophthalmoplegia, or vertigo as a result of brainstem lesion, superficially resembling acute labyrinthitis; hearing loss may also occur but is uncommon; painful tingling, burning, or electrical sensations in extremities.
10. Psychiatric: Depression experienced by approximately half of the patients; can be reactive, endogenous, or part of the illness itself, and can contribute to fatigue. Suicide in MS patients is 7.5-fold more common than in age-matched controls (4). Euphoria was once thought to be characteristic of MS but is uncommon, occurring in less than 20% of patients (4).
11. Musculoskeletal: Pain in limbs, spine.
Physical Examination
A comprehensive physical examination is vital to the identification of impairments related to the disease process. A neurological examination will provide clues to the various neuroanatomic locations of lesions. MS is primarily an upper motor neuron disease. The physical examination should assess the integrity of the following:
1. Corticospinal tracts (upper motor neuron signs: Babinski, clonus, Hoffmann signs, spasticity, hyperreflexia)
2. Spinocerebellar tracts (balance and coordination including rapid alternating movements)
3. Oculomotor function (i.e., nystagmus)
4. Spinothalamic tracts (pain and temperature)
5. Bulbospinal tracts (bulbar signs)
6. Dorsal columns (fine touch, proprioception, vibration)
7. Corticocortical connections (cognition: memory, alertness, orientation, attention, executive functioning, mental processing, visual spatial deficits, and communication)
Cranial nerves II, III, IV, and VI should be examined, especially if the patient complains of visual symptoms. Diplopia may be due to an internuclear ophthalmoplegia or an ocular motor cranial neuropathy, typically a sixth nerve palsy. The occurrence of bilateral internuclear ophthalmoplegia is considered to be highly suggestive of MS, especially in young patients. Third and fourth cranial neuropathies are uncommon in MS (6).
Spasticity is defined as a velocity-dependent increase in tone associated with upper motor neuron disease, which results in muscle stiffness, pain, loss of joint range, and function. The severity of spasticity is commonly evaluated using the Modified Ashworth Scale. Complications associated with spasticity include contractures, pain, loss of function, and skin breakdown.
Musculoskeletal examination should include inspection, palpation, and range of motion of the upper and lower extremities and spine, searching for possible causes of musculoskeletal pain in the MS patient. Motor strength should also be assessed in the extremities. Functional assessment should include an evaluation of the patient’s bed mobility, transfers, and gait. If the patient uses an orthotic, it is important to check for proper fit and for areas of skin breakdown. In nonambulatory patients confined to a wheelchair, it is important to check for proper positioning in the wheelchair.
There are several scales that can be used in the assessment of the MS patient. The extent of neurologic disability can be evaluated using the Kurtzke Expanded Disability Status Scale. This is a scale that grades the type and extent of disability on a scale from 1 to 10. It assesses eight functional systems—the higher the score, the more disabled the individual. A score of 10 represents death secondary to MS (7). Fatigue in MS can be assessed using the Modified Fatigue Impact Scale, Visual Analog Scale, Fatigue Severity Scales, and MS Specific Fatigue Severity Scale (8,9).
Impairments, Activity Limitations, and Participation Restrictions in MS
In order to monitor the natural history of MS and the impact it has on a patient’s life, impairments, activity limitations, and participation restrictions should be assessed. As defined by the World Health Organization, impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations (10).
An impairment is a loss of or abnormality in anatomical, physiological, or psychological structures or function. These abnormalities can vary widely in MS patients. Examples include short-term memory loss, impaired concentration, depression, fatigue, visual loss, paresis, paresthesias, impaired sensation, spasticity, footdrop, bladder/bowel incontinence, sexual dysfunction, and impaired balance and coordination.
MS patients have activity limitations as a result of their neuromuscular, psychological, and cognitive impairments. Paresis and increased tone leads to decrease in ambulation, transfers, activities of daily living (ADLs), and instrumental activities of daily living (IADLs). Spasticity can lead to pain and alterations in gait pattern that can increase the risk for falls. Depression is a common impairment that can be associated with sleep disturbances and poor concentration that can adversely affect IADLs and safety in the home. It is now recognized that impaired cognition can lead to impaired working memory, judgment, and processing speed. These can lead to difficulties in planning and organizing, cooking, balancing a checkbook, safely taking medications, and difficulties with reading. Without modifications in the workplace or at home to address certain functional limitations, problems can develop with the patient’s ability to participate.
Psychosocial, Vocational, and Educational Issues Affecting the MS Patient
MS has a significant impact on families, work, community, and educational activities. Fatigue, mobility impairments, and cognitive impairments were reported as the main drivers of job-related difficulties. MS has been shown to have an impact on the cessation of relationships and marriages compared to the general population. Interviews with some spouses who become caregivers to patients with MS express discontent with this new role or idea and express the desire to be loved as a spouse rather than as a caregiver (11). Onset of MS before 36 years of age and having children are good prognosticators for maintaining relationships or marriages compared to the opposite.
Participation restrictions can be especially devastating for productive young healthy individuals who depend on their physical, mental, and psychological capacity to care for themselves, family, and work. Studies have shown MS to have a strong impact on employment status, as the mean unemployment rate of those with MS was 59% (12). The rate of unemployment increases consistently with age and disease duration. Fatigue, mobility impairments, and cognitive impairments were reported as the main drivers of job-related difficulties, whereas employer’s lack of support and accommodations were identified as the causes of perceived discriminations (12). Loss of income is a significant concern for MS patients, who are typically affected by the disease during their peak financially productive years and can also face increased medically related costs.
Parenting is another important limitation that is often faced by patients with MS on a relatively large scale. MS is a disease of young adults in their reproductive and parenting age. During periods of MS exacerbation, patients are rendered physically and cognitively unable to care for their children and will often require hospitalization for treatment and rehabilitation.
Children of parents with MS can experience a shift to the role of caregiver, which can be overwhelming. It is important to provide early family counseling and intervention to maintain a healthy family unit and at the same time maintain a safe environment for the patient suffering from MS.
Individuals living with MS may have been active members of social or athletic clubs, which require a certain level of physical and cognitive functional capacity, and may face increasing challenges in continuing their roles in these activities as the disease progresses.
Rehabilitation Treatment Plan for the MS Patient
The rehabilitation treatment plan for the individual with MS should be driven by the impairments, activity limitations, and participation restrictions facing that person. Given the variety of different impairments associated with the disease, a team approach to care is recommended. For example,
1. Abnormal gait can be addressed through a physical therapy program that strengthens key muscle groups used in ambulation and provides gait training using an appropriate assistive device.
2. Spasticity management can be accomplished through a combination of medications, stretching, and use of modalities.
3. Swallow dysfunction can be addressed by speech pathologists following a formal assessment by recommending specific diet modifications and strategies.
4. Difficulties performing ADLs can be addressed by occupational therapists through appropriate training and recommended modifications to home environment.
5. Several members of the rehabilitation team such as neuropsychologists, occupational therapists, and speech pathologists can evaluate cognitive impairments with compensatory strategies provided to the patient and his or her family.
6. Vocational counselors can assist the patient with return to work issues.
7. Recreational therapists can provide information and strategies specific to return to leisure activities.
8. Driving rehabilitation can be useful for the individual with MS who needs to drive but is found to need training, as well as modifications to the vehicle.
9. The role of the social worker can be vital in identifying community resources for the patient, as well as for providing emotional support and counseling.
10. A psychologist and/or psychiatrist can evaluate for depression and provide treatment as needed.
11. Rehabilitation nursing can provide education and training regarding bowel and bladder care and medication use.
12. Medical and surgical subspecialties such as neuro-ophthalmology and neurology are also commonly involved in the care of the MS patient.
The exercise prescription for the MS patient should take into consideration the patient’s impairments so that exercise can be carried out safely. For example, risk of falls should be clearly communicated to the treating therapists. Fatigue and heat intolerance are additional concerns; hence, an exercise program should provide for adequate rest periods and minimize exposure to excessive heat environments.
MEDICAL KNOWLEDGE
GOALS
Demonstrate knowledge of established and evolving biomedical, clinical epidemiological, and sociobehavioral sciences pertaining to MS, as well as the application of this knowledge to guide holistic patient care.
OBJECTIVES
1. Describe the epidemiology, anatomy, physiology, and pathophysiology of MS.
2. Identify the pertinent laboratory and imaging studies important in MS.
3. Review the treatment and management of MS.
4. Examine the socioeconomic and ethical issues in MS.
MS is the most common cause of nontraumatic disability affecting young people in the Northern Hemisphere. There are about 400,000 persons in the United States living with MS, and the prevalence range is 40 to 220 per 100,000 people. The incidence of MS is 171/100,000 persons, with females accounting for approximately 70% of cases (3). Therefore, when a patient between the ages of 20 and 40 presents with these symptoms the clinician should be prompted to consider the diagnosis of MS. Patients may not seek medical attention if the impairment is not disabling. In addition, patients may experience symptoms that are nondebilitating that may not necessarily be indicative of MS.
MS is multifactorial in its causality. Environmental factors are thought to act as triggers in people who have a genetic predisposition to developing the disease (13). Investigators have shown an association between infection with Epstein-Barr virus (EBV) and patients with MS, implying that viruses may serve as triggers to manifesting the disease (14). MS also appears to involve genetic factors with HLA-DR2 in DR-positive families having a greater chance of developing the disease (13). Twin studies from different populations consistently indicate pairwise concordance (20%–30% in identical twin pairs compared to 2%–5% in like-sex fraternal twin pairs), providing additional evidence for a genetic etiology in MS (15).
MS pathology is marked by the presence of multifocal plaques of demyelination in the cerebral hemispheres, optic nerves, brainstem, and spinal cord (16). Myelin destruction is an essential element of the plaque. The plaque forming lesions in the brain has a temporal progression, based on stages of inflammatory destruction. Accordingly, acute, chronic active, and chronic silent lesions have a gradual progression, eventually producing the scarred and hardened areas within the CNS that can be appreciated via gross examination (17). The acute stage is typified by strong inflammatory infiltration combined with demyelination distributed throughout the lesion. The acute plaques include ill-defined margins of myelin loss, infiltration of immune cells, and parenchymal edema. A region of hypocellularity with loss of myelin and glial scarring characterizes the chronic plaque. In chronic active lesions, inflammation continues along the outer border comparable to acute lesions. Areas of remyelination are often observed on the edge of lesions. Chronic silent lesions are characterized by loss of the inflammation and inflammatory mediators along the border of chronic active lesions (17).
The chronic inflammatory process in MS patients is not confined to the white matter (18). Gray matter lesions are detected by MRI and by examination of pathologic specimens (17). As might be expected, inflammatory lesions within the gray matter are associated with neuronal loss and transected axons, which are more common in active lesions (17). The inflammatory process destroys myelin, oligodendrocytes, neurons, and axons. Active demyelinating lesions lead to high density of axonal transections that are persistent with low-level axonal damage in active plaque (19). In addition, there is diffuse axonal and neuronal loss throughout the nervous system. Macrophages are the most prominent inflammatory cells in the lesion and many are filled with myelin debris. MS pathogenesis has linked the disease process to myelin-specific CD4þ T lymphocytes, which upon activation by unknown factors migrate through the blood–brain barrier (BBB) and exert cytotoxic attacks on oligodendrocytes and myelin. EBV, a B-lymphotropic microorganism, has been implicated in the development of the disease by epidemiological, immune, serological, and histological studies (20).
There are several different types of MS:
Relapsing remitting MS is the most common and is characterized by periods of disease activity followed by periods of disease inactivity.
Secondary progressive MS is characterized by a relapsing and remitting course until the disease enters a phase of steady decline.
Primary progressive MS is characterized by a steady worsening of the disease without episodes of relapses.
Progressive relapsing MS in which there is a steady worsening of the disease with episodic relapses (21). Both primary progressive and relapsing and remitting MS were found to have an onset to progression at the ages of 40.2 and 38.6, respectively (22).
Diagnostic Testing in MS
The diagnosis of MS is primarily a clinical one with supporting evidence drawn from MRI, CSF analysis, and evoked potentials as needed.
1. MRI: MRI is currently the preferred imaging technique to support the diagnosis of MS. It is more sensitive than CT and may also identify subclinical lesions (23).
Multifocal areas of increased intensity on T2-weighted images are abnormal in 85% of cases. These are ovoid appearing plaques located in the periventricular white matter. Lesions are enhanced with gadolinium and may precede the onset of deficits and identify active disease. Subclinical lesions may be visualized. MRI will demonstrate disseminated lesions in space, replacing examination findings in two areas. Repeat MRIs over time showing new lesion formation can also be substituted for further attacks in making a diagnosis. The McDonald criteria (24) (Table 19.1) allow for consistent diagnostic criteria to be applied and are helpful in epidemiological studies as well as patient recruitment into clinical trials (16).
2. CSF analysis: Before MRI, this was the mainstay of study in MS. Cerebral spinal fluid: CSF protein and glucose is normal. There is an increase in oligoclonal IgG bands, IgG and WBCs.
3. Electrodiagnostic testing: Evoked potential responses: Visual evoked potentials (VEPs), brainstem auditory evoked potential responses (BAERs), and somatosensory evoked potentials (SEPs) have been used to aid in the diagnosis of MS (25). Absence or prolonged latency of responses has been noted.
CLINICAL PRESENTATION | ADDITIONAL DATA NEEDED FOR DIAGNOSIS | COMMENT |
Two or more attacks; objective clinical evidence of two or more lesions | None | If MRI or CSF analysis is negative, caution must be taken before making a diagnosis of MS |
Two or more attacks; objective clinical evidence of one lesion | Dissemination in space and demonstrated by MRI Two or more MRI-detected lesions consistent with MS plus positive CSF Evidence of further attacks implicating a different site | MRI scan must fulfill criteria for brain abnormality Positive CSF: Oligoclonal bands detected by established methods, preferably isoelectric focusing, different from any such bands in serum; or by a raised IgG index |
One attack; objective clinical evidence of two or more lesions | Dissemination in time demonstrated by MRI or second clinical attack | MRI scan must fulfill criteria for dissemination of lesions in time |
One attack; objective clinical evidence of one lesion (monosymptomatic presentation; clinically isolated syndrome) | Dissemination in space demonstrated by MRI Two or more MRI-detected lesions consistent with MS plus positive CSF and dissemination in space, demonstrated by MRI scan or second clinical attack | MRI scan must fulfill criteria for brain abnormality Positive CSF: Oligoclonal bands detected by established methods, preferably isoelectric focusing, different from any such bands in serum; or by a raised IgG index |
Insidious neurological progression suggestive of MS | Positive CSF and dissemination in space, demonstrated by nine or more T2 lesions in the brain or two or more lesions in the spinal cord, or four to eight brain plus one spinal cord lesion Continued progression for 1 year | Positive CSF: Oligoclonal bands detected by established methods, preferably isoelectric focusing, different from any such bands in serum; or by a raised IgG index Scan must fulfill criteria for brain abnormality |
4. Visual evoked potentials: Abnormalities are most consistently seen in MS and optic neuritis (1) and there is a high sensitivity along with MRI. A study by P. Asselman found that the latency of the VEPs was prolonged in one or both eyes in 84% of those with definite MS, in 83% of those with probable MS, and in 21% of those with possible MS (26). Electromyography (EMG) findings in MS have also been described (25).
TREATMENT
Medication
May be used to decrease inflammation and also suppress the immune system.
Corticosteroids
Used in the treatment of acute attacks or exacerbations. A systematic review found a sufficient body of evidence to support the use of IV methylprednisolone in acute exacerbations of MS (23). Symptoms most responsive to this treatment include optic neuritis, brainstem involvement, acute pain, and bowel and bladder dysfunction. The least responsive symptoms involved cerebellar and sensory dysfunction (23).
Immunomodulator Agents
Used to prevent disability caused by disease progression and decrease the severity, frequency, and exacerbations of the disease. These include (a) Interferon beta-1a (Avonex), (b) Interferon beta-1a (Rebif) (25), (c) Interferon beta-1b (Betaseron), (d) glatiramer acetate (Copaxone), and (e) natalizumab (Tysabri).
Immunosuppressive Agents
Used as second-line therapies. They are reserved for patients with unresponsive disabling MS. These include cyclosporine, cyclophosphamide, azathioprine, plasmapheresis, methotrexate, and mitoxantrone (27).
Rehabilitation Program in MS
During an acute exacerbation, treatment should include a comprehensive rehabilitation program, which includes the following: relative rest, hydration, bladder and bowel management, physical therapy, occupational therapy, speech therapy, neuropsychological treatment for cognitive retraining, and dietary management.
Prescriptions for physical therapy should be tailored to address specific impairments and safety concerns. Specific muscle training is recommended for improving focal weaknesses. Since weakness is a significant problem in MS, it is very important that generalized conditioning be maintained as long as possible. Fatigue management should also be implemented. Focused muscle strengthening that incorporates progressive resistive exercises, range of motion, balance, coordination, and bed mobility and transfers can be effective in motivated individuals with mild or even severe impairments. Passive and active training should be complemented by comprehensive instructions and advice to the patients and caregivers. A systematic review found that exercise training can help improve aerobic capacity, fatigue, health-related quality of life, strength, and mobility (28).
Treatment for spasticity is also very important, especially if the patient has issues with positioning or complains of pain. Treatment should include positioning, stretching, splinting, icing, and oral medications such as baclofen, dantrolene, tizanidine, and injections such as botulinum toxin. Home exercises should also be taught.
Balance and gait disturbances must be addressed. For those whose primary goal is gait improvement, exercise must include standing and walking. Gait evaluation should be made on level surfaces, rough terrain, stairs, and elevation. A systematic review found some evidence that ambulation training with robotic assistance may be of benefit to MS patients (29). Similarly, a systematic review of the evidence for physiotherapy on balance revealed a modest benefit for patients with mild to moderate MS (30).
Aquatic exercise (swimming, water aerobics, and water walking) has been recommended to improve aerobic endurance, strength, balance, and flexibility in a safe environment while avoiding potentially detrimental increases in body temperature. Care should be taken to find a pool that is not too hot (>29°C, 84°F) for those who are sensitive to heat.
Cooling therapy has been shown to reduce fatigue, improving postural stability and muscle strength in 10 heat-sensitive MS patients when wearing a cold vest with active cooling (7°C, 60 min). Postintervention pain intensity was significantly reduced in the experimental group compared to their counterparts who had nonaquatic exercise therapy (P < .028), and was maintained for up to 10 weeks (31).
Occupational therapy: Restoration and maintenance of functional independence skills in everyday activities is a key goal for managing the disease. Task reacquisition; performance of ADLs and IADLs; transfers; sensory/perceptual compensation; use of adaptive equipment; modification of environment for personal, domestic, and community tasks; and driving evaluation are key components of occupational therapy.
The occupational therapists should also teach the principles of “energy conservation” referred to as the “4 Ps” to these individuals. These include planning, prioritizing, pacing (budget energy throughout the day and week), and positioning (proper body mechanics, workplace ergonomics) (3). In addition, work simplification and ergometric techniques should be taught. Referral to a work hardening program is helpful. A systematic review of the scientific literature reported an improvement in arm and hand function with motor training programs in MS (32).
Speech therapy is rarely necessary for patients with MS but may be utilized in rare cases of aphasia. In patients with dysarthrophonia, speech training together with respiratory exercises may help to improve articulation (31). In the most severely disabled patients, impaired swallowing may be a risk for respiratory infections due to insufficient respiratory function and reduced coughing. In these cases, respiratory training may help in improving respiratory functions and cough reflexes (31).
Cognitive impairment is common in persons with MS and areas of strength and weakness should be defined. Various aspects of cognitive functioning, including attention, information processing efficiency, executive functioning, processing speed, and long-term memory, should be addressed. Cognitive testing should be included as part of the neurological evaluation, on account of the psychosocial implications of a cognitively impaired young productive adult with MS. Cognitive retraining will help the patient adapt to the disease and improve quality of life.
The physician as well as the nursing team should also address and teach patients who may have bladder dysfunctions secondary to MS. The type of bladder dysfunctions can be determined by urodynamic testing and with input from physicians who have expertise in the assessment and management of neurogenic bladder dysfunction. Urinary infection should be treated if present. Depending on the type of bladder dysfunction, the patient should be treated with medications and intermittent catheterization as needed. MS patients with neurogenic bowel dysfunction can be treated with the implementation of a bowel program.
ETHICAL ISSUES IN THE CARE OF MS
It is important that physiatrists providing rehabilitative care to individuals with MS understand the ethical principles of autonomy, beneficence, nonmaleficence, and justice (33). It is equally important to realize when ethical conflicts arise in the course of physician–patient relationships.
The principle of autonomy requires that patients with MS be fully informed of the risks, benefits, and alternatives regarding their care and can make decisions that are consistent with their beliefs and wishes that are free of intimidation. Facing increasingly complex decisions, patients need up-to-date evidence-based information and decision support systems in order to make informed decisions together with their physicians (34). The principle of autonomy can be challenging when the individual with MS does not have intact cognitive abilities, but insists on a particular course of action.
The principle of beneficence requires that physicians do their best to provide high-quality care to the patient with MS. This implies that they keep their level of competence and knowledge on MS up-to-date and always have the best interest in mind for the patient’s well-being. The principle of nonmaleficence refers to not harming the patient. Harm can come to the MS patient as a result of adverse reactions or side effects from treatments. In performing a benefit versus risk analysis, the physiatrist assesses beneficence versus nonmaleficence (33).
In the principle of justice, an important concept is the fair distribution of scarce resources such as medications, rehabilitation services, and mobility aids. Socioeconomic and racial disparities can serve as a challenge with the ethical principle of justice in the field of rehabilitation medicine. For example, there is some literature that more African Americans than whites experience pyramidal system involvement early in MS, leading to greater disability as measured by the ambulation-sensitive Expanded Disability Status Scale (35). This in turn can lead to limited access to these scarce resources by members of minority groups.
There are times when there can be an ethical conflict such as when a patient’s wishes are contrary to the best advice of the treating physiatrist (e.g., autonomy vs. beneficence). In addressing ethical conflicts it is always important to first determine which ethical principles are involved, determine the patient’s wishes, understand his or her belief system, identify any applicable laws or regulations that can provide guidance, and then seek common ground.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
