MS STEP UP Patient Cases: Advanced Clinical Reasoning for Treating Complex Patients with MS
Amy Collins, SPT and Amelia Cain, SPT
Background
We both began physical therapy school with an interest in working with people with neurologic conditions. Amelia’s love for the brain began while studying neuroscience at Ohio State University and continued to grow as she volunteered with Dance for Parkinson’s Disease and assisted with neurologic research. Similarly, Amy’s neuroscience minor at Wake Forest University and family history of MS and ALS led to her interest in neurologic rehabilitation. Our personal, educational, and professional backgrounds led us to pursue and be accepted into the Multiple Sclerosis Standardized Training and Education Program with University Partners (MS STEP UP) at UNC.
MS STEP UP began at UNC in 2008 with the goal of producing clinical leaders knowledgeable in treating patients with MS.1 In addition to the standard DPT curriculum, this program has awarded us a variety of invaluable learning, community, interdisciplinary, and teaching experiences to enhance our knowledge of multiple sclerosis. We have been fortunate to learn from and work with exceptional mentors through our education, neurologic clinical rotations, and through the MS STEP UP Volunteer Leadership Team (VLT). We are both passionate about advancing our clinical knowledge and ability with patients with neurologic conditions, contributing to the future of clinical care and of the profession through teaching and research, and remaining engaged in the profession as a whole. Collaboration with the VLT led us to this capstone project which will help to advance MS STEP UP scholars’ understanding of MS, and provide a template for the program to continue to grow and adapt to updated evidence.
Statement of Need and Purpose
A study funded by the National MS Society estimates that in 2017 nearly one million adults in the US were living the MS.2 MS is a complex, chronic, neurodegenerative condition associated with a variety of symptoms. 3,4 Physical therapy plays an integral role in improving and maintaining functional ability and optimizing quality of life for those with MS.4 Due to the complexity of MS and the need for comprehensive management, people with MS would benefit from access to healthcare providers who are specialized in managing their condition.4 The goal of MS STEP UP is to contribute to the development of physical therapists with specialized knowledge in MS.
MS STEP UP (Multiple Sclerosis Standardized Training and Education Program with University Partners) currently incorporates educational modules to be completed in the first year of the program; however, these modules would benefit from the inclusion of more relevant research and use of technology. Due to the rapid advancements in MS research, these educational modules would be enhanced by updating materials to reflect current evidence and establishing a structure which will allow for continuous incorporation of recent research. Currently, second-year scholars in the MS program primarily engage in more community- and research-oriented activities and are not required to complete additional educational modules. Advanced patient case modules intended for second-year scholars will provide supplemental material with crucial updates regarding MS, interactive discussion through forum posts between scholars and VLT members, advanced case-based problem-solving skills, and an outlet for continuous updating of the program.
The primary aim of this project is to provide current, relevant, evidence-based review of the topics touched on in the first year of the program, to promote advanced clinical reasoning through complex patient cases, and to establish a structure for continuous adaptation of the educational materials to include relevant research. The goal is that this will ultimately result in higher quality of care for our patients with MS.
We ultimately sought to create interactive, evidence-based, and updated modules built to enhance advanced problem-solving skills in MS rehabilitation and create an avenue for continuous updating of program content within MS STEP UP.
Overview
These advanced patient case modules in MS include two interactive cases of patients with moderate and advanced levels of disability, which have been expanded upon in order to review the many objectives of MS STEP UP. Each module consists of a thorough review of the subjective, objective, short-term and long-term plan of care, and rehabilitation considerations unique to MS. The modules are broken down into three parts per patient case with associated Voicethreads, objectives, and resources. Each Voicethread finishes with a forum post to be completed prior to continuing on to the next part. Upon completion of a forum post, the previous responses will be viewable and MS STEP UP members will be notified of a new post so that they can provide additional feedback and considerations. These modules also include a “hot topic” page which contains relatively new topics related to rehabilitation in MS. This part of the module thoroughly explores the available evidence on these new topics, and provides an outlet for the creation of additional hot topics that can be added to the program for continual updating. Outlines for how to create a “hot topic” and link it in Sakai are included under the Resources tab in Sakai to help standardize future hot topics.
Products
The final products include a review of current literature in MS rehabilitation and three Sakai-based educational modules. Two of the modules are based on patient cases and each includes three voicethreads and associated forum prompts. The patient cases were adapted to address the objectives of MS STEP UP and anticipated scholar competencies. The final module is for “hot topics” in MS rehabilitation and currently has two voicethreads (focused on high-intensity interval training for MS and central vestibular dysfunction in MS), as well as an outline and instructions for future hot topics. For those who do not have access to the MS STEP UP page, we have provided an outline of the Sakai lesson pages (linked below) as well as samples of our work through links to the hot topic voicethreads. For those with access to the MS STEP UP page, we have provided a link to the MS STEP UP Sakai Modules.
Hot Topic Voicethreads:
Evaluation
We have received and incorporated feedback from capstone committee members and VLT members throughout the creation of this project.
We created an evaluation survey in order to provide continual feedback on the effectiveness and relevance of our modules. This form will be completed by future cohorts of MS STEP UP Scholars to provide potential adjustments and additions to the materials as literature and research is advanced over time.
Health Literacy
The educational modules were developed for the anticipated audience of current DPT students and physical therapists. The advanced patient case modules incorporate a complex combination of social, financial, caregiver, education and other resource-related difficulties that require creative problem-solving. The inclusion of lower socioeconomic status (SES), financial, and education levels provide a greater understanding of the unique difficulties related to chronic disease when these issues are also relevant. The review of content from the first-year modules includes resources for patients with low levels of SES and education, requiring students to apply both these resources as well as creative problem-solving to best provide care for the patient with low health literacy in the module.
Self-Assessment/Reflection
Creating these modules has been an eye-opening experience into the complexity of multicomponent patient cases. This process was highly involved, requiring significant literature review and assessment of the best ways to incorporate problem-solving skills, advanced understanding of the literature, and review of so many areas within rehabilitation specific to MS. Performing such extensive literature review assisted our own learning of both new, innovative topics within the MS literature as well as reinforcing concepts learned during the first-year modules that we previously completed. This combination has allowed us to gain additional expertise in our knowledge of MS and its evaluative and treatment considerations as well as provided an avenue for us to give back to this program that has provided countless opportunities for us.
Navigating Sakai and Voicethread has been a complicated process with a long learning curve, but learning all of these skills has prepared us for potential teaching opportunities in the future, something we are both interested in pursuing. The small details and steps required to properly create a presentation on Voicethread and then inserting it into an interactive module on Sakai was a cumbersome process.
Lastly, our collaboration as a team has been ongoing for two years now. From flying to New York to gather patient data to our Grand Rounds presentation, this Capstone project has been an exciting, complicated, and fulfilling culminating effort during our time together at UNC. It has been such a rewarding experience working on this Capstone together as well as our review paper in our independent research study. We are so grateful and appreciative of each other’s support and assistance throughout all of our presentations and travels, this final project has been the most exciting!
Acknowledgements
We would not be where we are without the constant support and guidance from our MS advisor, Dr. Audrey Osinski, PT, DPT, NCS, MSCS. Not only has she served as our point person for this Capstone project, but she has served as our MS advisor. This project bloomed out of both the need within the program and the endless encouragement provided by Audrey. We are so grateful for her guidance in this Capstone journey as well as her mentorship in our personal and professional careers. We cannot thank her enough for all that she has done for us and MS STEP UP.
We could not have completed the many components of this project without the guidance of Dr. Lisa Johnston, PT, DPT, who oversaw and reviewed all of our many products and helped us understand the many intricacies involved with Sakai. She has been a crucial member of MS STEP UP since its initiation, and took over as our academic advisor when Dr. Prue Plummer moved to Boston for a new position at MGH. Her role as our Capstone advisor and academic advisor is furthered by her constant mentorship for us as we have grown throughout our time at UNC. She has proven a constant in UNC’s program and kept us afloat during this global pandemic.
From the beginning of our time at UNC, Dr. Prue Plummer, PT, DPT, PhD has supported our interests and aspirations in neurologic rehabilitation. Throughout the completion of our Capstone, she has provided valuable and extensive feedback and input, shaping our modules and the future of MS STEP UP. She oversaw MS STEP UP prior to leaving UNC, and has continued to be there for both of us despite her countless responsibilities and move up the East Coast. Her extensive knowledge in research, MS, and neurologic rehabilitation assisted with each component of our project.
The valuable feedback and input from Dr. Alexis Williams, PT, DPT, NCS cannot be overstated. Throughout our project, Lexie has provided constant support and guidance and we are so thankful for her input. As one of the VLT members and previous MS STEP UP Scholars, Lexie has been a role model for both of us.
We are so incredibly thankful for the National MS Society for their collaboration with UNC and sponsorship of MS STEP UP since its initiation twelve years ago. Specifically within the Society, Kaye Gooch has been a constant point person for us throughout our years in MS STEP UP and we are so appreciative of all her time and help!
A special thanks must go out to Dr. Michael Gross, PT, DPT, PhD who assisted us from the beginning, teaching us the ins and outs of using Voicethread and sharing his expertise! He has also been a constant for our third year class during these turbulent times, and we are so thankful for his support and assistance.
Additionally, special thanks and appreciation for Dr. Deborah Thorpe, PT, PhD who oversaw the Capstone coursework and Dr. Deborah Givens, PT, PhD who has confidently and bravely guided us through this difficult period of time. Our thanks cannot be put into words!
Lastly, we would like to thank Dr. Jessica Cassidy, PT, DPT, PhD who has mentored us in our research regarding stroke and the role of self-efficacy in neuroimaging. She has been a crucial member of our team and mentored us in numerous ways. We are both so excited to continue working on research under her guidance!
We are so thankful for all of the aforementioned people as well as all of the UNC Physical Therapy faculty and our class of 2020. It has been a pleasure learning from all of you and sharing this experience, and we are excited to continue watching the many successes to come!
References
- National MS Society. MS STEP UP Program for Doctor of Physical Therapy Students.https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Professionals/MS-STEP-UP-Scholarship-Program.pdf. Accessed April 13, 2020.
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- Kubsik-Gidlewska AM, Klimkiewicz P, Klimkiewicz R, Janczewska K, Woldańska-Okońska M. Rehabilitation in multiple sclerosis. Adv. Clin. Exp. Med. 2017;26(4):709-715. doi:10.17219/acem/62329.
- Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. Cochrane Database Syst. Rev. 2019;1:CD012732. doi:10.1002/14651858.CD012732.pub2.