Transcript Expanding Horizons in MS Care

Expanding Horizons in MS
Care
Stephanie Singleton, OTD, OTR/L
NMOTA Fall Conference
September 2, 2016
Albuquerque, NM
Objectives
 1) Participants will be able to state 3 resources to
provide their clients with community resources.
 2) Participants will be able to state 3 innovative ideas to
use in their work with someone who has MS.
 3) Participants will be able to articulate the importance
in the use of occupation when working with an individual
who has a chronic disease process.
Who in Attendance Today Knows
Someone who has MS?
 How many of you have a friend or family member who
has MS?
My Background
 OT Practitioner with 25+ years of experience
 Current practice setting: Out-Patient OT at Lovelace
Rehabilitation Hospital – Enchanted Hills and Jemez
Pueblo sites
 Diagnosed with MS: August 26, 2014
 Attended CMSC: June 2016
First Symptoms and Beyond…
 I had my first symptoms about 8 years prior to being
diagnosed. I had a full battery of tests run with no
results that pointed to MS.
 I had subsequent “flare-ups” of prior symptoms but no
further follow-up until I was hospitalized in 2014.
 I tried a variety of nerve glides to decrease
“symptoms”…
 I thought I was crazy but I kept coming back to the
possibility of what was “really going on”.
August 26, 2014
 Symptoms for about a week before that.
 Blamed it on being tired and stressed.
 Double vision got worse…
Overview of MS
Definition of Multiple Sclerosis
 Multiple sclerosis is a chronic demyelinating disease of the
Central Nervous System. It is characterized by both
inflammatory and neurodegenerative features and affects
both the white and gray mater of the brain.1
 In MS, the immune system attacks the protective sheath
(myelin) that covers nerve fibers and causes communication
problems between your brain and the rest of your body.
Eventually, the disease can cause the nerves themselves to
deteriorate or become permanently damaged.
 Signs and symptoms of MS vary widely and depend on the
amount of nerve damage and which nerves are affected.
Some people with severe MS may lose the ability to walk
independently or at all, while others may experience long
periods of remission without any new symptoms.2
Impact on the CNS
MRI of the Brain
Healthy Brain
Brain with MS
MRI’s
 “MS Protocol”
 It is the preferred imaging method to help establish
a diagnosis of MS and to monitor the course of the
disease. Identifies CNS demyelination.
 T1 weighted scan uses Gadolinium – enhances active
inflammation.
 Clinical relapses and MRI activity.
 Sagital Plane important in MS – front=motor,
rear=sensory
Prevalence of MS
 MS affects approximately 400,000 people in the US and 2.5 million
worldwide. (Autopsy studies suggest that these numbers can be
doubled.)
 In the US, prevalence estimates are approximately 90 per 100,000
population.

MS symptoms can start anywhere between 10 and 80 years of age,
but onset is usually between 20 and 40 years, with a mean of 32
years.
 Although MS is more frequently seen in Caucasians than African
Americans, the latter group appears to accumulate disability more
quickly, suggesting more destructive tissue injury in this population.
 The prevalence of MS varies by location and generally increases the
further one travels from the equator in either hemisphere. It
remains unclear whether this altered incidence represents an
environmental influence, genetic difference, or variable
surveillance.3
MS Impacts on Lifespan
 Life span is shortened 6–12 years (secondary to
complications in disabled MS, brainstem involvement,
and suicide).4
Factors Associated with Increased
Risk for MS
 Vitamin D levels
 Geographic Location
 Epstein Barr Virus (EBV) – Increase risk 13 fold
 Sunlight Exposure
 Genetics – 20%
 Viruses, bacteria
 Diet; high salt intake
 Birth month
 In Northern Hemisphere, increased risk for MS when born in
April/May vs October/November
Types of MS
 Primary Progressive- 10%-15% start with this – usually
40-60 year old’s
 Relapsing – Remitting- 85% start with this
 Secondary Progressive- 50% of those untreated
transition to this
 Progressive-Relapsing- 5% start with this
Definition of an Exacerbation
 An exacerbation of MS (also known as a relapse, attack
or flare-up) causes new symptoms or the worsening of
old symptoms. It can be very mild, or severe enough to
interfere with a person’s ability to function at home and
at work.
To be a true exacerbation, the attack must last at least
24 hours and be separated from the previous attack by
at least 30 days. Most exacerbations last from a few
days to several weeks or even months.5
Treating a Severe Exacerbation
 For severe exacerbations (involving loss of vision, severe
weakness or poor balance, for example) which interfere
with a person’s mobility, safety or overall ability to
function, most neurologists recommend a short course of
high-dose corticosteroids to reduce the inflammation and
bring the relapse to an end more quickly.
Disease Course
 Chronic, progressive, and disabling disease.
 Quite variable… every person is unique!
 Symptoms can include: weakness, spasticity, fatigue,
neuropathic pain, positive Babinski sign, numbness,
parasthesias, optic neuritis, neurogenic bladder, sleep
disorders, sexual dysfunction, vertigo.
Comorbidities
 Systematic review by Marr et al, was completed and
based on their meta-analysis, it was found that the most
common comorbidities for people with MS, were:
 Depression (23.7%)
 Anxiety (21.9%)
 Hypertension (18.6%)
 Irritable bowel syndrome (12.2%)
 Chronic lung disease (10%)6
WHO ICF “Breakdown” of MS
Body Structures Impacted by MS
 Brain
 Spinal Cord
 Immune System
 Voice and speech Structures
 Musculoskeletal System
 Visual System
 Genitourinary System
 Digestive system
MS and the Brain
 Brainstem – densely packed – lesion here can cause
really big problems!
 Wallenberg Syndrome – can be ignored by the ER and
passed off as drunk.
 Ventral Pons lesion – worst scenario – causes “Locked in
Syndrome” .
Gray Matter
 Gray matter volume loss noted on MRI’s impacts long term
disability
 Researchers have found that patients with multiple sclerosis
(MS) lose myelin in the gray matter of their brains in
relative amounts equal to or greater than myelin loss in the
brain’s white matter.
 The results showed that gray matter demyelination was
much more advanced in patients with secondaryprogressive MS, and was strongly related to patients’
disability. 7
 Myelin content in gray matter is extremely important for
proper function.
 Vitamin D supplementation may impact gray matter
preservation
MS and the Spinal Cord
 Lesions here can be very problematic due to area being
tightly packed bundle of sensory and motor fibers
 Can cause bowel and bladder issues and issues with
sexuality
MS and the Eyes
 Optic Neuritis – lesion is in the eye that is weak
 Can have pain with movement of the eyes
 Loss of vision
 Double vision
 Blurred vision
 It’s very important to recognize triggers of visual
deficits!
Body Functions Impacted by MS
 Neuromusculoskeletal and movement related Functions
 Cognition
 Swallowing
 Sensation and Pain Functions
Activities and Participation Areas
that can be Impacted by MS
 General Tasks and Demands
 Communication
 Movement
 Self Care
 Domestic Life Areas
 Learning and Applying Knowledge
 Interpersonal Interactions and Relationships
 Major Life Areas
Symptoms of MS
Symptoms of MS
Symptom Management
 Many symptoms are inter-related.
 Symptom management is extremely important in order
to maximize function and quality of life.
 A multi-disciplinary, collaborative approach is necessary
to meet the needs of the client.
Invisible Symptoms
 Fatigue
 Depression
 Sexual Dysfunction
 Bladder Dysfunction
 Bowel Dysfunction
 Visual Changes
 Pain
Fatigue - #1 Symptom - 80%
 Functional MRI shows that people with MS expend more
energy on daily tasks
 Fatigue can persist over time
 Primary (acute) fatigue and Secondary (chronic) Fatigue
 Thyroid issues can also cause fatigue
 Good sleep hygiene
 Restless leg syndrome
 Researchers at CSU have proposed a new definition of
fatigue to be used in research
 Fatigue Severity Scale, Fatigue Impact Scale, MMT before
and after 6 minute walk test
 Suggest use of an Activity Diary
Pain and Sensory Issues
 Lhermitte’s Sign – generally associated with acute cord
lesion
 Spasticity pain – affects 50-60%
 MS Hug
 Options to decrease pain include: Exercise for
endorphine release and use of Tricyclic anti-depressants
and/or Neurontin
Non-pharmacolcogical
Management Approach to
Symptoms
 Fatigue: Exercise, Energy Conservation, Cooling
stratagies
 Spasticity: ROM, Stretching, Relaxation techniques,
Positioning
 Gait Problems: Mobility aids, Exercise, AFO’s, FES
devices
 Pain: Meditation, Mindfulness, Relaxation techniques
 Bladder Dysfunction: Timed voiding, Bladder diary
 Depression: Exercise, Helping others, Engagement in
Occupations
Rehabilitation for the MS
Population
Life With MS
Traditional Care
 Up to a decade ago,
people with MS were told
not to exercise. It was
believed that the stress
on your body and the
rise in temperature was
detrimental.
Current Concepts
 Current research shows
that exercise can
increase health and
perception of quality of
life.
Importance of Exercise
 Increased endurance and strength
 Increased self-esteem
 Decreased risk for depression
Exercising Impacts
 A small study was completed by Razazian, et al that
found that exercise has impacts on fatigue, depression
and parasthesia in female patients with MS.
 Their conclusion was that exercise training programs
should be used in conjunction with the standard of care
medication.8
Types of Exercise
 Yoga
 Tai-chi
 Resistance training
 Aquatic Therapy
 Walking
 Hippotherapy
 Pilates
 Adaptive Sports
Rules for Exercise
 2 hour rule- You should feel better or the same 2 hrs
after exercise
 Monitor fatigue using RPE scale
 Encourage use of proper footwear
 Re-check every 6 months to maintain appropriate levels
Endurance Training
 This is a feasible option, even with people who have a
progressive disease process.
 Temperature Regulation – very important to monitor and
compensate for. Cooling vests can really help!
What is CMSC?
 Consortium Of Multiple Sclerosis Centers
How Did I Become Involved with
CMSC?
 NMOTA connections (be sure to stop by the New Mexico
MS Society table in the exhibit hall!)
 Huge shout out to Vicki Kowal!!!
CMSC 30th Annual Meeting
 June 1-4, 2016
 National Harbor, Maryland
 Over 1900 in attendance (Neurologists, Researchers,
Nurses, Rehab Professionals, etc.)
 9 Concurrent tracks (Basic Science, Research,
Rehabilitation, Disease Management, etc.)
 Next meeting: May 24-27, 2017 in New Orleans, LA
Some Areas of Discussion at
CMSC this year:
Roundtable on Rehab Issues
 In MS, the worry about reimbursement issues is not on
coverage of the meds but it is on coverage of rehab
services.
 Need evidence to back up our services- efficacy.
 Insurance wants to know number of visits needed
(orthopedic view).
 Fee for service model is going away and going towards
bundled payments.
Rehab Roundtable, con’t.
 Why do we discharge patients with neurological issues,
particularly neurodegenerative issues?
 Lawsuit Jimmo v. Sebelius (2013 district court of
Vermont) : maintenance based skilled intervention
(whether skilled care is required).
 D/C report: follow the dentist model where the patient
is discharged but it is left open tor them to come back
when there is a change. *Patients leave on a better
note using this model.
Advocacy Committee Meeting
 Concerned about access to treatment in changing
healthcare reimbursement arena
 Medicare restrictions on DME: ex: BSC’s being denied
unless bedbound or home is a 2 story home where
access is limited.
 Other insurance companies are requiring letters of
medical necessity for bathroom equipment.
 Cost of medicines (they are being paid for but due to
limitations in funds, therapy may not be paid for).
 Average person with MS changes insurance every 2
years.
New Mexico Connections
 Corey C. Ford, MD, PhD, Co-Chair of the Continuing
Professional Education Committee
 From the Multiple Sclerosis Specialty Clinic at the
University of New Mexico/Health Sciences Center
 My neurologist! Thank you Janet Poole!
Entertainment – Clay Walker!
Latest Research in MS Care
 Gut Microbiome
 Antihistamines
 Vitamin D
 Use of Gaming Systems
The Role of the Gut
 Gut Microbiome – largest immune system in the body
 All mucousal areas have microbiomes
 Gut:Brain axis – controls motility of the gut
 Antibiotics change the gut flora and we never catch up
once we have stopped taking them
 You are what you eat! (Anti-inflammatory foods are good
and good for you!)
Gut Bacteria
 Harvard Researchers found significant differences
between gut bacteria of people with and without MS.
 Further research is needed, but, researchers are
currently stating that they think that there might be
future treatment using diet alterations.9
 National MS Society is funding The MS Microbiome
Consortium to determine factors that drive progression
and to develop probiotic strategies for stopping
progression.9
Antihistamines and MS
 A small study by Green et al, showed promising results
of partially reversing optic neuropathy with allergy
medications (antihistamines).10
 The standard options for dealing with optic neuropathy
are steroid injections, use of an eye patch, and use of
medications to ease the side effects of visual
disturbances.
MS and Vitamin D
 37th Parallel
 Ecological Implications
 Vitamin D status may matter in utero
 Vitamin D may impact the immune system and may help
regulate cell growth and differentiation.
Vitamin D and MS
 Active trial at 15 sites nationwide
 Use caution with observational study information
 Weigh the risks (possible increase in kidney stones and
heart disease) with the benefits
 D3 may be easier to use
 Re-check levels after 3 months of use
Microsoft Kinect
 Using a gaming camera that detects movement and
computer algorithms that quantify people’s walking patterns
can help clinicians objectively monitor the differences in gait
of multiple sclerosis (MS) patients compared to healthy
individuals, a study says. In current clinical practice, the
walking movement of MS patients is usually assessed by
their doctors, and subjective evaluations may distort
results: two different clinicians may give the same patient
different evaluations.11
Medications
 Disease Modifying Therapies (DMT’s) – target various
steps of the inflammatory/ neurodegenerative process.
 They include: Copaxone, Gilenya, Tysabri, Betaseron,
Avonex, Rebif, Aubagio, Tecfidera, Avonex, Novantrone,
Extavia, and Alemtuzumab ( Alemtuzumab was just
approved by FDA in June 2016). 12
 Emerging DMT’s include: these that are in Phase 3
studies: Ocrelizumab, Daclizumab, Laquinimod and
Siponimod. 13
Process of Getting onto
Medication…
 Insurance generally
dictates what medication
you start on.
 I had to start with
Copaxone (injection) and
had to “fail” before
starting on an oral
medication, Gilenya, June
2015. Which I have since
“failed”. At the beginning
of August, I started
Tysabri, which is an
infusion drug, one time
per month.
 Special instructions for
new medications.
Cost of MS Medications
 A study in Neurology estimated that the traditional
DMT’s initially cost from $8,000-11,000 and now cost
around $60,000/year. The newer drugs that are
entering the market cost about 25 – 60% more that the
originals. This is 5-7 times higher than prescription drug
inflation.14
Indicators of Treatment
Adherence to Injectable DMT’s
 Predictors of adherence to DMT’s include: self-efficacy,
hope, perceived health care provider support, family
support, positive patient education, perceived benefits of
adherence, and use of an injection device.15
Evidence of Rehabilitation in
Working with the MS Population
 Regarded as weak in strength of evidence – however the
article used pharmacological levels
 We don’t systematically collect evidence on outcomes
What We as OT Practitioners Can
Do for those Living With MS
Outcome Measures
 COPM
 Multiple Sclerosis Functional Composite
 Timed 25 Foot Walk
 9 Hole Peg Test
 Paced Auditory
 Multiple Sclerosis Quality of Inventory – battery of 10
individual scales which have both a standard and a short
form available
 Individual scales include:
 Modified Fatigue Impact Scale
 Perceived Deficits Questionnaire
 MOS Pain Effects Scale
 Impact of Visual Impairment Scale
Use of Occupation
 Come on, we are OT practitioners, we know this!
 But sometimes, we get “caught up”…
 However, particularly when working with someone who
lives with a chronic disease process…
What Restricts Participation in
Occupation?
 Ask the questions…
 What supports their current performance?
 What do they want or need to be able to do?
 What equipment or techniques are they currently using?
 What is their support system like?
 What is important?
Occupation Based Activities
 Speaking from personal experience, I went through a
grieving period where I did a lot of “Life Before MS vs
Life After MS”
 It is true that when one door closes, another door or
window opens…
My Future Endeavors
 Member of the National MS Society’s South Central
Region Healthcare Advisory Committee
 Supports the committee in its charge to increase quality of
care for people with MS, and improve access to that care.
 Member of the Subcommittee: Partners is MS Care
(PiMSC)
 Leverage relationships with colleagues and introduce them
to the Society
 Mentor providers who have interest in learning more about
caring for MS patients and work towards deepened
engagement
OT Interventions
 May focus on:
 Education for health and disease management
 Prevention
 Remediation for lost or limited abilities
 Compensatory skills
 Maintaining functional performance
 Advocacy issues
Lifestyle Modification for
Continued Participation
 Provide Education on:
 Energy Conservation
 Alternative Pain Control Techniques
 Advocacy
 Relaxation Techniques
 Alternative Techniques Training
Cognitive Issues
 Cognitive difficulties may be under-recognized but can
impact the areas of: complex attention, executive
functioning, word finding, episodic memory, working
memory and processing speed. Processing issues are
the most likely to be impaired in the MS population.
 2 easy tests that can be used to screen for cognitive
issues are: Symbol Digit Modality Test and MoCA
 TUG and Cog Tug – Difference of greater than 10% is
considered significant
 It is recommended that a baseline neuropsychological
evaluation be completed, as follow-up can impact
disability evaluation.
Neuroplasticity
 Make activities relevant
 Make activities functional
 Challenge using dual tasks – example standing to blow
up a beach ball
 Translate evidence into practice
 Target the area of weakness
 Incorporate video and/or computer games
Addressing Cognitive Issues
 Strategies to compensate for deficits that may be
present in the clinical setting, include: repetition and
providing written literature.
 Physical exercise training can increase cognitive status
(ex: yoga increases attention)
Fall Risk
 Early intervention needs to include targeted, personal
interventions
 Near-falls are extremely common in individuals with MS
 Identifying risk factors is not enough – must mitigate
them as well
 Ask the questions. Meds, near falls, falls, what
happened, injuries, where they able to get up, where
assistive devices in use?
Fall Risk Scales and Monitors
 MS Walking Scale – client self report- High reliability and
validity
 Activities Specific Balance Confidence Scale
 Falls Efficacy Scale – International
 Fall Diary – can be used to monitor falls and near-falls
 Hopkins Fall Grading Scale
 TUG and T25FW- are more accurate for non-fallers
 Combination of objective and subjective measures
Adaptive Equipment
Traditional
 Shower chair
 Grab Bars
 Reacher
 Sock aid
Not-so traditional
 Bar stools
 Animal assisted therapy
 Smart phones
 Back pack
 Front porch steps
Technology
 Apps for phones: MS Self (helps track life with MS and
provides information about MS)
 MS101.me available on iTunes and Google play – helps
track MS Factors (symptoms, meds, stress, sleep, etc.)
 National MS Society’s MS Diagnosis, Disease and
Symptom Management App for Healthcare Professionals
 Facebook: Healthline: Living with Multiple Sclerosis :
MSBuddy
Exercise Equipment
 FES Powered
Systems(16)
 Reverse muscle atrophy
 Reduces muscle spasms
 Improves local
circulation
 Increases range of
motion
Mobility Equipment
 Hiking Poles
 Walkers
 Hip Flexion Assist Device (HFAD)
 Alinker
 Stair Chairs
 Bioness
 Lofstrand crutches
 ReWalk Exoskeleton - $69,000
Hip Flexion Assist Device (17)
Alinker 18
Bioness L300 and L300 plus (19)
ReWalk Exoskeleton (20)
Healthy Living
 National MS Society “Stretching for People with MS: An
Illustrated Manual”
 Adaptive Yoga Moves Any Body by Mindy Eisenberg
 Yoga and Multiple Sclerosis by Loren Fishburn
(Author), Eric L Small
 Alternative Medicine – acupuncture, massage, etc.
 Healthy Diet
Encourage Check-ups with other
Healthcare Professionals
 Have a primary physician
 Have regular eye exams
 Be aware of potential hearing changes and assess as
needed
 Promote safety and environmental modifications as
needed
 Assess for swallowing deficits
To Diet or Not to Diet…
 Most claims that have been touted as “cures” are based
on personal accounts vs. science.
 However, there is some evidence that a diet low in
saturated fats and supplemented by Omega-3 and
Omega-6 may have some benefit for people with MS.21
 Currently, most MS specialists recommend that people
with MS adhere to the same low-fat, high fiber diet
recommendations of the AHA.
Mental Health
 Mental Health Issues: Inflammation impacts depression
 Virtual MS Support Group = My Counterpain- which is
used to chart the persons journey and helps them gain
perspective. It can also be used by caregivers.
 2x as likely to experience anxiety and mood disorders
 Limited mental health providers are available nation
wide.
Summary
Key Points to Remember…
 A diagnosis of MS is not the end of life, it is merely a
new chapter.
 When you are working with someone who has MS:
 Work on occupation
 Work on meaningful activities
 Work on energy conservation techniques
 Work on community resources
 Work on advocacy issues
More About MRI’s
 It is important for people with MS to be aware that
disease activity can occur even in the absence of new
lesions.
 Dr. Lily Jung Henson stated, “Even when no new scarring
is apparent, the scars that have occurred in the past are
still there, and there could be activity occurring
underneath the surface,” she explains. “Perhaps most
important, the absence of new lesions doesn’t mean that
a patient can start thinking about discontinuing his or
her medications. Previous activity may be under control
because of the disease-modifying agent a patient is
taking.”22
Remind Your Clients That It’s a
Process…
 Some days we are better at adapting to what life throws
at us.
 Don’t sweat the small stuff.
 Be honest, with yourself and others.
 Ask for help, offer help.
Lessons That I Have Learned…
 Live in the moment!
 Be joyful!
 Be thankful!
 Don’t over-plan!
 Have wonderful friends!
Things that I have Changed in
my Life…
 Energy conservation techniques
 Planning out activities with rest breaks in mind
 New exercise routine
 Use of yoga in my clinical practice
 Use of Lofstrand crutches when hiking
 Warm versus hot showers
Why
 ad·vo·ca·cy (ăd′və-kə-sē) n. The act of pleading or
arguing in favor of something, such as a cause, idea, or
policy; active support. advocacy23
Fundraising Efforts
 Walk MS
 Bike MS
 Muckfest
 Direct Contributions to
the National MS Society
 2016 Walk MS
Albuquerque
Resources
New Mexico MS Society Chapter
 New Mexico
 Tel: 505-243-2792 Fax: 505-468-8022 Email:
http://www.nationalmssociety.org/Chapters/NMX
 Albuquerque Trade Center, 3540 Pan American Freeway
NE Ste F
Albuquerque, NM 87107
Ongoing Research
 Encourage participation in CMSC’s NARCOMS. This is a
long-term study of people with MS. Anyone who is
diagnosed with MS can participate. Participation can be
completed on-line or by mail
 Data collected is used to help researchers, patients, and
healthcare move closer to finding a cure for MS.
Resources for People with MS
 National MS Society
 New Mexico MS Society
 Multiple Sclerosis Foundation
Resources for People with Visual
Deficits
 The Library of Congress National Library Service for the
Blind and Physically Handicapped (NLS) provides a
variety of free programs including:
 braille and audio material
 currency readers
Helpful Websites for People with
MS and MS Practitioners

For those who are newly diagnosed http://www.nationalmssociety.org/about-multiplesclerosis/newlydiagnosed/index.aspx

http://www.nationalmssociety.org/

http://activemsers.com/

Consortium of MS Centers http://www.mscare.org

http://ms-coalition.org

http://iomsrt.mscare.org

http://www.mscando.org – for professionals and people living with MS – focuses on
empowerment programs

http://msconnection.org

http://msfocus.org

http://msonetoone.com

http://MoveOverMS.org – tools, tips, videos

http://multiplesclerosisnewstoday.com – latest research and advocacy news designed for
patients and caregivers

http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Documents/MS
-in-focus-4-Emotions-and-cognition-English.pdf - handout on emotional and cognitive issues
Professional Organizations
 National Multiple Sclerosis Society
 International Organization of MS Rehabilitation
Therapists (IOMSRT)
 Multiple Sclerosis Certified Specialists
 Multiple Sclerosis Association
Final Thought…
 Hopefully, some day soon, MS will stand for Mystery
Solved!
Questions????
Acknowledgements
 I want to take a moment to thank my wonderful support
group… My partner, Barbara, who seems to know me
better than I know myself. She is a constant source of
encouragement and support! My friends who have stood
by me (literally and figuratively) on this new journey,
and to my “AI Sis”, who understands what I go through,
because she goes through “junk”, too!
 Thank you all, from the bottom of my heart! You mean
the world to me!
References
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1 Mallucci G. et al. The role of immune cells, glia, and neurons in white and gray matter pathology of multiple sclerosis. Prog. Neurobiol. 2015; 127-128:1-22.
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2 The Mayo Cllinic. Obtained from http://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/home/ovc-20131882 on 8/21/2016 on 8/21/16.
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3 Cleveland Clinic. Obtained from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/multiple_sclerosis/ on 8/21/16.
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4 A 3 Dimensional View of a Personalized Approach to Multiple Sclerosis: Effective Current and Emerging Therapy CME Presentation presented at CMSC on 7/01/2016.
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5 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 7/29/16.
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6 Marre RA. Et al. A systematic review of the incidence and prevalence of Comorbidity in Multiple Sclerosis: overview. Mult Scler. J. 2015; 21: 263-281.
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7 RSNA. Obtained from https://www2.rsna.org/timssnet/media/pressreleases/14_pr_target.cfm?ID=758 on 8/24/16.
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8 Razazian, N. Et al. Exercising Impacts on Fatigue, Depression, and Parasthesia in Female Patients with Multiple Sclerosis. Med Sci Sports Exerc. 2016; 48(5):796-803
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9 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 7/21/2016.
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10 Obtained from CMSC. CMSC INforMS Newsletter on 7/19/2016.
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101Obtained from http://www.mscare.org/news/303991/CMSC-INforMS-Researchers-develop-technology-for-treating-multiple-sclerosis-with-gaming-cameras.htm on
8/24/16.
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12 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 25.
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13 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 35.
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14 Neurology. Obtained from http://www.neurology.org/content/84/21/2185.full on 7/29/2016.
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15 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 62.
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16 Photo obtained from Restorative Therapies website on 8/22/2016.
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17 Photo obtained from Beckerorthopedic website on 8/11/16.
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18 Photo obtained from Alinker website on 8/9/16.
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19 Photo obtained from Bioness website on 8/24/16.
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20 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 8/05/16.
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21 Photo obtained from http://rewalk.com/rewalk-rehabilitation/ on 8/24/2016.
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22 Obtained from the National MS Society Magazine website http://www.momentummagazineonline.com/demystifying-mris/ on 8/24/2016.
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23 Definiton obtained from www.thefreedictionary.com/advocacy on 8/6/16.
Thank you! Enjoy the rest of
NMOTA conference!
 Please make sure to attend the Silent Auction and bid on
the wonderful items where the proceeds benefit our
NMOTA Student Scholarship fund through AOTF!