results objective 1. figure 1. flow chart of disease ... · this case report shows an example of...

The Effects Of a Long-Term Multidisciplinary Disease Management

Program: A Case Report Evan T Cohen, PT, MA, PhD, NCS1, John T Marmarou, PT, DPT2 and John R Armando, LCSW2, (1)School of Health Related

Professions, University of Medicine and Dentistry of New Jersey, (2)Total Rehab and Fitness, LLC

Background There is a paucity of evidence for the use of long-term

multidisciplinary care lasting longer than six months for

persons with multiple sclerosis (MS). This case report

describes the results of a person’s year-long episode of

care in the Disease Management Program (DMP), a

multidisciplinary, medically-based rehabilitation service

and health management program for persons with MS.

The DMP provides services based on each person’s

needs. Each DMP participant undergoes a quarterly

reassessment. Additional reassessments may be

conducted if new patient- or clinician-identified

problems arise.

Objectives 1. Describe the DMP as applied to a person with MS,

and describe the person’s status from the baseline

examination through 15-months of participation in the DMP.

2.Describe the feasibility of the DMP in improving

function and quality of life for persons with MS.

Methods The baseline assessment was conducted by the DMP team members at intake. This included both the standard set of measures collected from all DMP

participants and a discipline-specific examination by respective DMP team members. The designation of services was based on goals identified by the person

with MS and the DMP team. Once the person’s progress stabilized, a transition to the maintenance phase was initiated. If issues arose during the

maintenance phase or at a quarterly assessment that indicated need, the person reentered the skilled phase. This cycle was repeated over the 15-month-long period

resulting in the collection of data for the baseline and five regular quarterly assessment. A flow chart of DMP processes can be found in figure 1.

Results Objective 1. The person completed 15-months of the DMP despite three unexpected events: two separate orthopedic foot injuries, and a crisis of hope and optimism. These

problems were identified early through the DMP’s routine and special assessments. This facilitated redesignation of skilled services which enabled the person to continue participation in

the DMP. From baseline to the 15-month measurement, the person improved all components of the Multiple Sclerosis Functional Composite (figure 2) and in 7/9 items of the

Multiple Sclerosis Quality of Life Inventory (MSQLI) (figure 3). Improvements were also noted in 6-Minute Walk and Four-Square Step tests, walking speed, and in the number of

reported falls (Figure 4). Objective 2. The program described here was a person-

centered multidisciplinary rehabilitation and health maintenance program with a relatively low cost. The interventions provided by the DMP were well tolerated and

resulted in substantial improvements across a number of important outcomes. This case report shows an example of the steady improvements that can be achieved through the

use of a persistent, long-term health maintenance program, even when unexpected events may temporarily derail progress. The DMP appears to be a feasible intervention and

health management program for persons with MS.

DMP Intake,

Orientation and

Baseline Examination

Designation of

Services Skilled Phase

Maintenance/

Prevention Phase

Special

Reassessment

Routine Quarterly

Reassessment

Services May Include:

Hand Therapy (with OTR/L)

Functional mobility retraining (PT)

Cognitive Therapy (SLP)

Acceptance and Commitment and/or

Behavioral Therapies (Behavioral Therapist)

Functional improvements

stabilize/plateau

Figure 1. Flow Chart of Disease Management Program Processes

Expected Transition

Unexpected Transition

Figure 2. MS Functional Composite Components

0

1

2

3

4

5

6

7

8

1 2 3 4 5 6

Seco

nd

s

25' Timed Walk Test

Baseline Q1 Q2 Q3 Q4 Q5 0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5 6

Co

rrect

An

sw

ers

3-Second Paced Serial Addition Test

Baseline Q1 Q2 Q3 Q4 Q5

0

5

10

15

20

25

30

1 2 3 4 5 6

Seco

nd

s

9-HPT - Non-dominant Hand


5

10

15

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25

30

1 2 3 4 5 6

Se

co

nd

s

Nine-Hole Peg Test – Dominant Hand


Figure 3. Multiple Sclerosis Quality of Life Inventory Components

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6

Sco

re

SF-36 Physical Component Summary


10

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60

70

1 2 3 4 5 6

Sco

re

SF-36 Mental Component Summary


2

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1 2 3 4 5 6

Sco

re

Modified Fatigue Impact Scale


2

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Sco

re

Bladder Control Scale


2

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1 2 3 4 5 6

Sco

re

MOS Pain Effects Scale


-1

0

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4

1 2 3 4 5 6

Sco

re

Bowel Control Scale

Baseline Q1 Q2 Q3 Q4 Q5 -1

0

1

2

3

1 2 3 4 5 6

Sco

re

Impact of Visual Impairment Scale


10

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80

1 2 3 4 5 6

Sco

re

Mental Health Inventory


2

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1 2 3 4 5 6

Sco

re

Perceived Deficits Questionnaire


10

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1 2 3 4 5 6

Sco

re

Modified Social Support Survey


2

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Seco

nd

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Four Square Step Test


0

100

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1100

1200

1300

1 2 3 4 5 6

Feet

6-Minute Walk Test Distance


-2

0

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1 2 3 4 5 6

Incid

en

ts

Number of Falls in Prior Two Weeks

Baseline Q1 Q2 Q3 Q4 Q5 Baseline Q1 Q2 Q3 Q4 Q5

0

0.2

0.4

0.6

0.8

1

1.2

1 2 3 4 5 6

Mete

rs/S

eco

nd

6-Minute Walk Test Average Walking Speed


Figure 4. Other Outcome Measures

Conclusion In this case study, the year-long DMP resulted in substantial improvements from baseline for this person with moderate

MS-related disability. Despite a number of potentially

problematic events, the person was able to adhere to this long-term program. The DMP team felt that the use of Acceptance and Commitment Therapy was critical to this

person’s success. Although the overall trend was toward improvement, quality of life (QOL) (i.e. the MSQLI components) showed the greatest variation.

The DMP shows promise as an efficient, effective and feasible multidisciplinary intervention program. Further study is required to fully determine the feasibility and effectiveness of

this long-term multidisciplinary program for persons with MS of different severities, and to determine how the DMP may be altered to have a more consistent positive impact on QOL.

The Disease Management Program at Total Rehab and Fitness is supported, in part, by a Community

Impact Grant from the Greater Delaware Valley Chapter of the National Multiple Sclerosis Society

results objective 1. figure 1. flow chart of disease ... · this case report shows an example of...

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