Case Study 11

NOTE: this scenario is identical to the previous scenario, except for the underlined text.

A 46-year-old patient with secondary progressive MS has worsening spasticity and difficulty walking. He has had no clinical relapses or active MRI lesions for >2 years. Medications include anti-CD20 antibody therapy (for nearly 5 years) and an antispasmodic for urinary symptoms. His last physical therapy session was almost 1 year ago. The patient immigrated to the United States about 20 years ago and has since learned to speak fluent English.

At the current visit, he reports increased unsteadiness when walking, especially longer distances. He complains of fatigue and pain in both legs, but mainly on the right. He also reports increased urinary frequency and urgency. Examination reveals lower extremity weakness, hyperreflexia, and spasticity (right>left). A review of notes from the previous 3 clinic visits and the current visit reveals the following results of Timed 25-Foot Walk (T25FW) tests: