WalkAide. Long term cost effectiveness of FES. J of Rehab Med 2013; 45(2): Humphreys et al

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1 WalkAide Long term cost effectiveness of FES J of Rehab Med 2013; 45(2): Humphreys et al 126 people (62 stroke, 39 MS, 7 SCI, 3 CP, 15 other) Mean time of FES use 3.6 years 33 using FES after 11.1 years MS walked 29% faster 40% increased Functional Walking Capacity 1

2 Gait DVDs Employment Issues in MS 2

3 Employment Issues Disease modifying drugs mean people with MS may work longer Should be addressed EARLY Don t wait until performance has declined Usually need to address multiple issues Employment Assessment Be aware of MS symptoms that may affect ability to maintain employment If patient is employed, always probe regarding possible problems Ask specifically about whether a particular symptom is affecting the job Don t offer support on disability application until modifications have been tried 3

4 Employment Treatable Symptoms likely to influence job performance: Spasticity Fatigue Cognitive problems Impaired gait Weakness Poor balance Decreased sensation Dizziness Pain Employment Treatment: Medications Disease modifying medication Fatigue meds Walking Ampyra Spasticity meds Bladder meds Botox Depression 4

5 Employment Modifications: Conserve Energy Separate exercise and function Obtain gait equipment Manage spasticity Decrease walking/lifting/stairs/prolonged standing Get and use a disabled parking space Identify a resting location Use power mobility equipment for long distances Substitute technology for physical and cognitive issues Employment Modifications: Technology Use technology to increase job performance Elevator Computers/tablets/smart phones Text Conference calls Webcasts Phone alert reminders Apps: Vbox, Dragon Dictate, Siri/Iris 5

6 Employment Modifications: Cognitive Issues Paper back up of steps to turn on/off technology Hints of bigger concerns Refer to other professionals for more in depth assessment and treatment Employment Modifications: Decrease heat Most people with MS are heat sensitive: Move to cooler location Air conditioning Use cooling vest Avoid prolonged exertion Work from home during hot periods D Meier, et al, Neurology 2010;75:

7 Employment Modifications: Ergonomic Changes Modify posture/positioning to decrease spasticity/fatigue Ergonomic work station Blue tooth, keyboard, tablet set-up, key pad for tablet, mouse, monitor, head set Individually fitted chairarmrests/headrest/height/back Head set/smart phone dock Voice activated software/apps Employment Resources for Modifications: Vocational Rehabilitation Employer National MS Society or other nonprofits Insurance for mobility equipment Building Owner Special grants Person with MS 7

8 Employment Disability Working people with MS may need to take disability Try modifying employment, behavioral changes, equipment before disability application Employment Disability Existing Functional Capacity Evaluations (FCE) often inappropriate for MS Existing FCE s based on orthopedic problems New MS FCE must capture relapsing remitting nature of MS as well as variable symptoms for each person 8

9 Employment Disability CMSC task force to develop new MS specific FCE May be used for reasonable accommodation recommendations Spasticity in MS 9

10 Assessing Spasticity in MS Evaluate spasticity routinely - regardless of specific complaint Spasm Frequency Scale Modified Ashworth Scale Dynamic Muscle Tone Multiple Sclerosis Spasticity Scale (MSSS-88) Clinical measure of pain intensity Spasm Frequency Scale Scor Criteria e 0 No spasms 1 No spontaneous spasm (except with vigorous stimulation) 2 Occasional spontaneous spasm and easily-induced spasms 3 More than 1 but less than 10 spontaneous spasms per hour 4 More than 10 spontaneous spasms per hour (Penn, 1989) 10

11 Assessing Spasticity in MS - Modified Ashworth Scale Score Criteria 0 No increase in tone 1 Slight increase in tone (catch and release at end of ROM) 1+ Slight increase in tone, manifested by a catch, followed by minimal resistance throughout remainder (less than half of the ROM) 2 Marked increase in tone through most of ROM, but affected part(s) easily moved 3 Considerable increase in tone; passive movement difficult 4 Affected part(s) rigid in flexion or extension (Bohannon & Smith, 1987) Dynamic Muscle Tone Observation of Movement Patterns Equinus gait Scissor gait Upper extremity flexion/adduction Mass movement postures Observation Tips Try observing with and without orthoses or ambulation aids Video taping can be very helpful 11

12 Symptoms and Signs Associated with Spasticity Excess: Spasms Hyperactive DTR Clonus Co-contractions Stiffness/heaviness Pain Sleep disturbance Fatigue Insufficient: Strength Dexterity Speed of movement Coordination Motor control Precipitating factors Exacerbation of MS Progression of MS DMT effects Antidepressant therapy Fractures/Skin lesions/urinary stones Fatigue/temperature/stress Menses/fever/infections Other noxious stimuli: tight clothing or constipation 12

13 Treating mild to moderate MS Spasticity Exercise Stretching/Yoga Rhythmic exercise Medications Oral Equipment Shoes Orthotics Assistive devices Wheeled mobility equipment Mild to mod spasticity (continued.) Behavioral and environmental changes ADL modifications 13

14 Exercise Treating moderate to severe MS Spasticity Stretching/Yoga Rhythmic exercise Medications Oral ITB Equipment Mod to severe spasticity (continued) Shoes Orthotics Assistive devices Wheeled mobility equipment Standing frame BWSTT/Lokomat Behavioral and environmental changes 14

15 MS Spasticity MS Spasticity: Take Control DVD Other Equipment in MS 15

16 Wheeled Mobility Equipment Manual wheelchairs Scooters Power wheelchairs Indications Excessive fatigue Severe weakness Ataxia Mobility Decisions Manual wheelchair vs scooter Manual wheelchair vs power wheelchair Scooter vs power wheelchair When to discontinue scooter When to add tilt and/or recline What about standing? 16

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20 Equipment Examples Cooling vest Cane Lightweight forearm crutches Four-wheeled walker with seat and hand brakes Front-wheeled walker Hinged ankle-foot orthosis Standing frame Three-wheeled scooter Manual wheelchair Power wheelchair Seating Employment Wheelchair Vehicle lift, ramp, lock downs Hand controls Conversion van Equipment Examples Elevated toilet/seat Hard flooring surfaces Padded bath transfer bench Ramps Grab bars for toilet/shower Low shelves/drawers Superpole with trapeze Reverse or offset hinges Sliding board Electric door openers Overhead lifts Voice-activated software Partner-patient lift Electronic memory aids Hospital bed or elevating Environmental controls head/feet Cell phone/smart phones Bed Ladder Telephone headset Buttonhook Adjustable Horizontal or vertical eating spoon keyboard/mouse tray 20

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25 Cognition and Multiple Sclerosis MS Cognitive Problems Affect 50% of people with MS Occur at any stage of disease Related to number & area of brain lesions Related to brain atrophy May vary from minimal to severe 25