Less Traditional Interventions Lead to Dramatic Changes for Young Woman with Neuromyelitis Optica

Background: Neuromyelitis Optica (NMO) onset is characterized most often by an acute episode, and if left untreated, can result in irreversible nerve damage with devastating impacts on functional mobility and eyesight. December 29, 2020, 22 year old “Ellie” presented to emergency room with persistent nausea/vomiting, blurred vision, and profound upper/lower extremity weakness. Imaging of the brain and spine revealed longitudinally extensive lesions from C2-C6 and C7-T5. Ellie received 5 days IV Solumedrol with prednisone taper. On January 8, 2021 she was admitted to Inpatient Rehabilitation (IP Rehab) with positive NMO antibody test. Rituximab infusions were completed 1/19/2021 and 2/2/2021. Ellie spent 8 weeks in IP Rehab and 24 weeks in Outpatient Rehabilitation (OP Rehab).

Objectives: 1. State three less traditional treatment approaches incorporated by the multidisciplinary team. 2. Describe the benefits of a carefully coordinated treatment schedule for persons with NMO.

Methods: Outpatient initial evaluations revealed Ellie was dependent for all mobility to include hoyer lift transfers and power chair mobility. Gross strength was 2+ to 3-/5 BUEs and 0 to 1/5 BLEs. Dependent to Max A for activities of daily living (ADLs). Bladder control was dependent with foley catheter. Impaired vision, executive function, voice volume and breath control were all present. Medical team meetings were held with Ellie and her parents throughout her plan of care to facilitate full compliance with recommendations. All OP clinicians who treated Ellie work at a specialty center for people with demyelinating diseases. Less traditional treatments included activity based neuromuscular stimulation of several muscle groups at one time, vision exercises and bladder training. Additionally, respiratory training was done to improve voice volume and to increase success with functional tasks. All aspects of OP PT, OT and SLP were carefully coordinated so as not to over fatigue her extremely weak muscles, as well as to reinforce carry over of strategies from one discipline to the next. Solumedrol infusion was repeated in July 2021 and Rituximab infusion just prior to OP discharge September 2021.

Results: At the conclusion of 24 weeks of OP Rehab, Ellie had a remarkable recovery in the areas of mobility, bladder function, vision and respiratory status. Ellie became Mod I for all transfers and ADLs. She was Mod I walking limited community distances with rollator walker and bilateral semi-hybrid ankle foot orthoses. She regained bladder control without catheter. She no longer required prism glasses and improved her visual fields. Ellie's executive function and problem solving dramatically improved. Finally, her respiratory status more than doubled.

Conclusions: Incorporating less traditional treatment interventions, along with a carefully coordinated schedule and team communication contributed to Ellie's relatively quick progress.