A competitive advantage in the market can be gained by gaining the trust and loyalty of clients via working with them as well as understanding their requirements. Most organizations use customer relationship management to manage interactions with prospective customers their target. Effective client relationship leadership can assist startups in optimizing their organizational processes and developing relationships with their clients to increase sales, improve customer services, and boost the company’s revenue. This concise report describes our new Smart Travel business, its services, and how Salseforce.com will be utilized to launch the company.
Smart Travel is a travel services company offering taxi, limousine, bus, rail, and tour travel services. The company will offer private and luxurious transportation using a variety of vehicles, including buses, cars, trains, as well as limousines. The enterprise will not follow regular schedules or routes, unlike typical buses or vehicles. It will capitalize on the expanding business & luxury travel services sector in the US due to customers’ increased spending power on travel luxuries like limousines and taxi journeys. The company will collaborate with numerous travel service providers, including administrative personnel and chauffeurs. Tourists, hotels, business travelers, tours & travel companies, private households, government officials, corporate executives, and students are the clients and prospective clients targeted by the travel services. Customer service is a hindrance to effective travel services implementation because it can have a negative impact on customer sales and satisfaction. Therefore, Smart Travel must develop efficient client relations strategies that demonstrate a genuine and sincere interest in consumers as well as give it a competitive edge in the travel service sector. This startup’s expansion will necessitate necessary and supplementary technological resources, such as customer service software, customer relationship management, and marketing automation (Sneha& Krishna, 2018). The instruments will enhance customer engagement, customer satisfaction, and customer experience. However, the company will utilize Sales-force software solutions for innovative applications that will assist Smart Travel in achieving its ultimate startup goal of offering private and comfortable conveyance services.
Smart Travel will use Sales-force mobile, analytics, cloud, and social technologies to establish its digital strategies when launching its travel service business. Numerous prosperous businesses use Salesforce to automatically monitor and analyze client interactions and ensure that their sales and marketing personnel target and follow up with clients most effectively. Sales-force cloud capabilities will grant the company mobile access to all travel-related service inquiries from prospective customers. By integrating mobile techs into Smart Travel’s lifecycle, Sales-force will facilitate the digital transformation of business processes that will revitalize customer experiences and leverage technological advances in the travel service sector (Campbell et al., 2020). Sales-force will also enable the organization to create and manage its social media interactions and presence simply yet effectively due to its analytical features, such as artificial intelligence and robust algorithms that can provide incisive business intelligence. Balancing the numerous Sales-force technologies, such as cloud, mobile, and analytics, will facilitate digital transformations when launching a business.
In addition, Sales-force will monitor the company’s customer support activities as it begins operations. Sales-force cloud services provide customers access to live chat, integrated mobile experiences, automated websites, and email services, enabling businesses to provide seamless customer service. Automated assignments prioritize customers’ travel requirements, improve customer service, and increase overall customer satisfaction. In addition, Sales-force supports consumer and business engagement by providing real and actionable travel service industry insights. It offers consumer and business partners portal options for collaborations in society, enhancing business and customer engagements. Clients and partners significantly impact the travel industry, and providing a social collaboration platform for customers and partners is essential. Sales-force provides the components that enable partners and customers to record leads and services, collaborate, and gain access to the tools necessary to close travel deals as well as service contracts.
Smart Travel will utilize Sales-force to promote innovation in the travel services industry when launching its operations. Chatter is a feature of Sales-Force that enables businesses, clients, and partners to share engaging articles, videos, experiences, and websites that keep people up-to-date on trends that can significantly influence sales, customer experiences, and profits (Davis, 2019). Sharing videos, experiences, and articles fosters an innovative culture and connects individuals, allowing for answers, queries, as well as feedback from any department or location. It enables collaborative problem-solving via customer and partner feedback. The accompanying diagram summarizes how salesforce.com will be utilized by Smart Travel to launch the company.
Fig.1. Sales-force diagram for Smart Travel
Campbell, C., Sands, S., Ferraro, C., Tsao, H. Y. J., & Mavrommatis, A. (2020). From Data to Action: How Marketers Can Leverage AI. Business Horizons, 63(2), 227–243.
Davis, A. (2019). Mastering Sales-force DevOps: A Practical Guide to Building Trust While Delivering Innovation. Apress.
Sneha, MS & Krishna Prasad, K.(2018). Analysis of Business Strategies of Sales-force. Com Inc. International Journal of Case Studies in Business, IT and Education (IJCSBE), 2(1), 37-44.
Scarface, The 1932 Film Essay Example
Scarface, the 1932 film adaptation, depicts Antonio “Tony” Camonte’s rise to prominence as Chicago’s most ruthless gangster lord. The real-life criminal leader Al Capone, who dominated the 1920s alcohol industry during Prohibition, inspired the film’s protagonist. Tony Camonte, an illegal immigrant, assists Johnny Lovo, a local mafia leader. He goes against the order not to interfere with the O’Hara faction, who rule the city’s northern reaches, and murders their commander. He then goes on to assassinate his employer and rise to the position of Chicago’s most powerful crime lord. Camone’s sister accuses him of killing her husband, providing the authorities with the opportunity they have hoped for. Tony, besieged by police, hides in a home until he is shot and killed in the film’s last scene. The first critical reaction to the film was quite adverse. There were complaints about too much blood, gore, and explicit language. This study thus offers a genre analysis of Scarface (1932). Furthermore, the film’s potential significance is tested by investigating how it departs from standard norms.
Q1. The film centred on gang members’ criminal activities. As a result, there were explicit depictions of violence and bombing. However, influential community members and self-proclaimed moral judges opposed action films and advocated that Scarface be restricted because it glorified violence. U.S. authorities were concerned that gangster movies might promote criminality. American regulators were concerned that viewers might want to emulate the film’s gangster characters. Discussions on crime in the media often pivot to the justification of violence and, by extension, the maintenance of societal order. Protests arose against the 1932 film Scarface because it influenced people for evil. The public at large does not support the presence of criminals.
Scarface appeased the Code enough to get a brief showing by modifying its final scene, cutting off very violent scenes, and incorporating a prologue condemning criminals. Still, the mafia film’s violent material and protagonist-led crime, like Goodfellas, would not get past State and city-wide censorship offices. Consequently, conditions such as New York, Ohio, Virginia, Maryland, and Kansas, as well as towns such as Seattle, Detroit, Portland, and Chicago, all prohibited the screening of Scarface. The movie was eventually banned in five cities and five states and heavily restricted in others—the extensive adjustments needed to be revised to satisfy State and local censor boards. The primary point of contention was between Hughes and the New York censor board. After the film was prohibited, the organization refused to display the sanitized conclusion(Yogerst,2017).
In the 1930s, gangster films were trendy, a trend sparked by gangster films. It was a period of societal turmoil, upheaval, and violence. Society’s morals have been brought into question as a result of the Great Depression. High unemployment, an influx of new immigrants, and the ban on alcohol sales dominated daily life in the United States. Scarface, directed by Howard Hawks and Howard Hughes, was released in 1932, prompting renewed controversy over the appropriateness of such behaviour. Scarface had fallen prey to a social change movement brought on by the economic crisis, its aftereffects, and the resulting social and moral difficulties in the United States. one that is critical of the way American culture promotes violence and moral decay. With the advent of sound and extraordinary lighting effects, the cinema industry had also begun a period of profound transformation. The general public’s opinion of movies might be affected by these factors. A result that can both enlighten and amuse while also pushing its audience’s cognitive boundaries and influencing the direction of popular culture.
Adults are less likely to be negatively impacted by Scarface’s violence than children are because they already have strong moral convictions. However, the effect of movies on minors is far more significant than on adults. When children are exposed to violence, they learn it is a better way to resolve disagreements than through peaceful means. There is evidence that exposing minors to violent media may have long-lasting effects on their worldview and level of empathy. Scarface is a dangerous and upsetting picture to show to anybody, especially young children, because of its overt and subtle immorality and excessive violence.
There has been an increased call for a halt to the creation of gangster movies since the debut of Scarface. Studios, still keen on drawing in big crowds, react by making sexual content, rather than blood and gore, a central selling element. Rabbis condemn Hollywood and its primarily Jewish studio leaders and the Catholic Church responds by forming the Legion of Decency. Through threats of film boycotts, the Church exerted enormous pressure on Hollywood studios, prompting Hays to choose Roman Catholic Joe Breen to head the Production Code Administration in 1934(Doherty,2019). Breen is heavily involved in rewriting screenplays and fining production companies that violate the Code. The PCA lost influence after Breen’s resignation in 1954 due to a Supreme Court antitrust verdict against studio-owned theatres. The movie picture industry in Hollywood unanimously agreed to a voluntary age grading system proposed by the MPAA in 1968. The argument over controversial scenes in movies continues unabated.
Furthermore, per MPAA guidelines, only adults or minors accompanied by an adult are allowed to watch the Scarface remake from 1983. Brian De Palma helms the picture; he has been criticized for the “brutality” of his previous works. Before its final screening, the picture had to be changed to pass muster with the Hays Office. These alterations were tasteful because they stayed true to the Lord-Quigley Code’s Prohibition on disproportionate violence. Some of the film’s more violent scenes were also placed in perspective by this, giving the impression that the filmmakers were only reporting on the story rather than trying to profit from it.
The Supreme Court sustained the conviction of a California publisher for disseminating pornographic materials in Miller v. California, 413 U.S. 15 (1973). The standard it set for determining when creative works pass over into uncensored obscenity was thus born. In Miller v. California, the Supreme Court established a new framework for identifying what constitutes obscene content for government regulation(Klika,2019). The three-part test asks whether the ordinary person, using current community standards, would believe the work to have no real literary, artistic, political, or scientific merit; to appeal primarily to prurient interests; and to represent sexual activity in an objectionable manner (Padgett,2021).
I believe Scarface was not a violent movie; instead, it simply represented the violence already present in society at that time. Scarface, released in 1932, is undeniably considered a cult masterpiece today. Even for modern viewers, the film’s unfiltered and accurate portrayal of criminal activity, gang conflict, and the culture of the 1930s during the Great Depression is disturbing, demonstrating both the filmmakers’ courage and determination. Even if they may have been negative initially, the challenges and controversies surrounding its first release only contribute to its reputation and mythology in modern times. The director of Scarface fashioned the movie in a manner congruent with the social events occurring at the time in the nation, regardless of acts of violence or corruption.
In conclusion, conventions specific to the Scarface film genre helped establish the nature of the cinema. They focus primarily on the criminal element, which is bolstered by violence. Other cliches, like the locale, are less critical in identifying the kind of film than they were. Characters of Italian ancestry were featured prominently in the majority of gangster films made during the golden age of the genre in order to portray life in the 1920s in the United States accurately. On the other hand, contemporary fiction might have characters from various periods and settings who interact with one another. There has been a shift in how the film industry is governed as a direct result of the violence in gangster films.
Doherty PhD, W. (2019). The American Catholic Church Censors the Movies.
Klika, C. (2019). The First and Second Amendments Are Not Mutually Exclusive: A Look at the First and Second Amendments after the Unite-the-Right Rally in Charlottesville, Virginia. Rutgers JL & Pub. Polly, pp. 16, 39.
Padgett, E. S. (2021). Dirty Pictures. Semiotic Review, 9.
Yogerst, C. (2017). Hughes, Hawks, and Hays: The Monumental Censorship Battle Over Scarface (1932). The Journal of American Culture, 40(2), 134.
Screening Of Multiple Sclerosis Essay Example
Multiple sclerosis is an autoimmune central nervous system disorder that can cause disability. The immune system attacks the myelin sheath protecting the hence causing difficulties in communication between the body and brain (Dobson & Giovannoni, 2019). Damage to or degeneration of nerve fibres might become irreversible as the disease progresses. The etiology is unknown, although some risk factors have been established. They include; family history, certain diseases, vitamin D deficiency, the presence of the chromosome 6p21 gene, obesity, and smoking (Dobson & Giovannoni, 2019). People with this condition have varying symptoms. Common presentations include weakness and numbness of the limbs, unsteady gait, lack of coordination, loss of vision, fatigue, vertigo, and cognitive problems.
I. Presentation of the Patient
The patient is a 45-year-old post-menopausal woman. She has a history of multiple cesarean sections. The patient was referred by her Primary Care Provider (PCP) to a physical therapist for physical therapy exercises following pelvic floor weakness and urinary incontinence secondary to multiple cesarean sections. She has a past medical history of vitamin D deficiency, obesity, multiple cesarean sections, and Hyperthyroidism. The patient is originally from Amsterdam and now residing in Alaska. She is a homemaker with a sedentary lifestyle. She has a long history of smoking. Upon examination, PT noticed the patient was tired and lethargic. After a week of treatment, the patient’s condition was not reversed. Patients complained of extreme fatigue and loss of vision on the left side. The patient also complained that she had a sensation of rotation of self and surroundings. PT found positive Lhermitte’s sign on reevaluation.
Presentation of PT Diagnosis
The patient is a 45-year-old post-menopausal woman with multiple and four cesarean sections history. Physical therapy was sought as an intervention for the patient after a diagnosis of pelvic floor weakness and urine incontinence. This led to a referral from the patient’s primary care physician. With a cesarean section, an incision is made to the lower abdominal area under spinal or general anesthesia. Additionally, to access the uterus, the bladder is moved aside. Hence, pelvic floor and pelvic floor muscle issues increase with numerous pregnancies and cesarean procedures. There is a significant reduction in the morbidity and function of the pelvic floor. Changes in pelvic floor function result in symptoms such as urinary incontinence, pelvic pain, and prolapse. This explains the physical therapy diagnosis of pelvic floor weakness (Quaghebeur et al., 2021).
Presentation of Medical Diagnosis
The patient’s medical history points to several risk factors that could have contributed to the diagnosis of multiple sclerosis. She presented with a history of vitamin D deficiency, multiple cesarean sections (4), obesity, and Hyperthyroidism. Additionally, the patient is a homemaker with a sedentary lifestyle and a long history of smoking. On examination, the PT noted the patient to be tired and lethargic. After a week of treatment, no improvements were noted, and the patient complained of extreme fatigue and loss of vision on the left side. She also complained of having a sensation of rotation of self and surrounding. On reevaluation, the PT found positive Lhermitte’s sign and referred her to her primary care provider, who made the multiple sclerosis diagnosis.
II. Red Flags of the Medical Diagnosis
Several red flags point to the medical diagnosis of multiple sclerosis. This includes the patient’s history of vitamin D deficiency, obesity, four cesarean sections, and Hyperthyroidism. The patient now resides in Alaska, which receives little sunlight, explaining the vitamin D deficiency. Her sedentary lifestyle and long smoking history also contribute to the medical diagnosis. Additionally, the patient presents with symptoms that are suggestive of multiple sclerosis. These include fatigue, lethargy, vision loss, vertigo, and positive for Lhermitte’s sign.
Red Flags of the Presenting Patient History
The patient presents with a history of Vitamin D deficiency. Studies have shown a linkage between vitamin D deficiency and multiple sclerosis. Deficient vitamin D levels cause increased brain lesions, which in turn cause demyelination, causing multiple sclerosis (Dobson & Giovannoni, 2019). Additionally, the patient recently relocated to Alaska. Recent research has focused on the hypothesis that Vitamin D insufficiency is more common the farther north and south one lives from the equator.
Moreover, MS is more rampant in the north. Northern countries with less solar exposure have the highest rates of multiple sclerosis. However, the effects of inadequate sun and vitamin D generation on immune system functioning have not been adequately studied (Dobson & Giovannoni, 2019). It has also been established that people living in Alaska struggle with Vitamin D deficiency due to less solar exposure, which explains the patient’s history of vitamin D deficiency.
Consequently, the patient has a long history of smoking. This significantly contributes to multiple sclerosis development (Dobson & Giovannoni, 2019). Research shows that hereditary and environmental factors can affect multiple sclerosis (MS) susceptibility. Cigarette smoke exposure is recognized as an environmental risk indicator for MS, leading to a higher chance of developing the disease and a more rapid progression once it has manifested. Smokers are approximately 1.5 times more likely to acquire multiple sclerosis than nonsmokers (Dobson & Giovannoni, 2019). In addition, a person’s genetic makeup and exposure to other environmental risks may interact with smoking significantly. Evidence from observational research suggests that smoking may affect how severely disability progresses in people with MS. Clinical relapses, new MRI-visible lesions, and quicker conversion after a first-ever demyelinating symptomatic episode are all outcomes connected to smoking.
The patient is a homemaker and lives a sedentary lifestyle contributing to significant health co-morbidities. Also, the patient is obese, possibly resulting from her sedentary lifestyle. Multiple sclerosis may be influenced by obesity in various ways. It causes the release of inflammatory cytokines and causes chronic low-grade inflammation (Faka Schulte, 2020). In addition, people with MS are at an increased risk for developing heart diseases, hypertension, and high cholesterol, all of which increase the likelihood that the person will become disabled.
There are several recognized mediators of this process. Important roles are also played by hormones released by fat tissue, known as adipokines. These adipokines can be pro-inflammatory, causing inflammation, or anti-inflammatory, reducing inflammation. The pro-inflammatory adipokines released by obese patients are uncontrollably high. These adipokines were found to enhance the likelihood of acquiring MS by increasing the development of neurodegenerative alterations. Multiple sclerosis and the impairment caused by the condition have been linked to adipose-derived hormones such as pro-inflammatory leptin and adiponectin (Faka Schulte, 2020). High leptin levels and low adiponectin levels, for instance, cause a decrease in the generation of T cells that regulate anti-inflammatory cytokines in obese patients. Potentially raising the likelihood of multiple sclerosis and difficulties associated with it are these factors. This explains the linkage of the patient being obese to multiple sclerosis.
The patient has a history of Hyperthyroidism. Multiple sclerosis (MS) and thyroid disorders have been reported to often co-occur in studies. The thyroid gland is located directly below Adam’s apple at the front of the neck. Additionally, thyroid disease has been linked to occur concurrently with multiple sclerosis. It may manifest naturally as a result of MS or as a side effect of therapy for MS. The thyroid gland regulates how food is converted into energy in the body (Faka Schulte, 2020). This is accomplished by controlling the release of certain hormones. Thyroid illness can cause either an overactive or underactive thyroid. Thyroid disorders, like multiple sclerosis, can have an autoimmune element.
Red Flags of the Presenting Subjective Complaints
The patient reports feeling tired and lethargic. Patients with multiple sclerosis are particularly vulnerable to this. Secondary factors, including brain injury or alterations cause it. The damaged nerve prevents the brain from communicating effectively with the rest of the body. Because of this, the physique must work harder to do basic tasks, which can exacerbate fatigue over time. Due to alterations to the brain that influence the demands on the muscles and the brain, multiple sclerosis commonly presents as fatigue. (Makhani & Tremlett, 2021). This explains the extreme fatigue and lethargy reported by the patient.
Additionally, the patient reports vision loss in the left eye. Most commonly, people with MS often initially notice symptoms when they have trouble seeing. Optic neuritis, an optic nerve inflammation, is a common visual sign of multiple sclerosis. Optic neuritis is an optic nerve inflammation that can lead to headaches, sensitivity to light, and even loss of color vision in one eye (Makhani & Tremlett, 2021). Inflammation can lead to symptoms when MS damages the nerves in a person’s eyes.
Consequently, the patient reports vertigo which she describes as a “sensation of rotation of self and surrounding.” Lesions, or damaged areas, in the multiple mechanisms that regulate visual, spatial, and other input into the brain required to establish and maintain homeostasis are to blame for these symptoms (Makhani & Tremlett, 2021). With MS, vertigo is typically brought on by the progression of an existing lesion or the development of a new lesion in the brain stem or cerebellum, the regions responsible for maintaining equilibrium.
Red Flags of the Presenting Objective Findings
The patient was found positive for Lhermitte’s sign by the PT on reevaluation. In this, demyelinated nerves fail to communicate correctly, leading to Lhermitte’s sign. An electric-like shock is triggered during the stretching the hyper-excitable demyelinated dorsal column of the spinal cord, especially at the cervical level (Makhani & Tremlett, 2021). This is the pathophysiology of Lhermitte’s sign. Excessive excitability has been identified as a key pathophysiological factor in the etiology of this disorder. From an etiological standpoint, Lhermitte’s initial research postulated that medullary lesions induced by demyelination or trauma to the dorsal column were responsible for the shock-like feelings (Makhani & Tremlett, 2021). Lhermitte’s sign is reported to be exacerbated by neck movements, with flexion of the neck said to generate the phenomenon and extension of the neck said to induce the opposite symptoms. Lhermitte’s sign, a symptom of multiple sclerosis, results from injured spinal nerves reacting to neck movement. As a result of the shift, the nerves lose some of the protection provided by their myelin coating, leading to miscommunication. There may be no actual tissue damage, yet the brain may still register the sensation as painful.
Decisions Related to Keeping the Client
Based on the presenting symptoms and the medical diagnosis established, the patient needs to be hospitalized. This will facilitate close monitoring and further consultations with other healthcare practitioners such as radiologists, nutritionists, nurses, physicians, and other concerned professionals in establishing a definitive diagnosis and an effective care plan. Also, close monitoring of the patient will ensure that further potentially life-threatening complications are avoided. This will also ensure a function of interprofessional collaboration in implementing the necessary medical interventions.
Decisions related to Alterations in the Plan of Care
It is essential to carry out further diagnostic tests to establish a definitive diagnosis and rule out other conditions that manifest similarly to MS. These include blood tests, MRI, lumbar puncture, and an evoked potential test. Further, studies have recognized an association between drugs used to treat MS and the worsening of thyroid disease. Therefore, it is essential that the primary care provider considers the treatment options and adjusts them appropriately. Further, it is essential to refer the patient to a rehabilitation team in addition to physical therapy. Through this, assistive devices are identified to enhance a sense of well-being and achieve desirable health outcomes.
Additions to the Plan of Care
Exercise is mandatory. The historical survey hints that exercise recommendations for MS care have changed over the past three decades. This narrative review demonstrates that exercise is safe and helpful for managing symptoms and altering illness course. Neurologists play a crucial role in the treatment process; hence the authors urge them to administer and promote exercises using prescriptive therapeutic exercise standards at the time of diagnosis and throughout the disease trajectory as part of comprehensive MS therapy (Hauser & Cree, 2020). The onset of the disease’s negative symptoms can be slowed considerably by engaging in regular physical activity, which has several positive effects. It is crucial to select workouts that cater to both the client’s skills and deficiencies. Improved mood and general well-being are two other outcomes of regular exercise.
The resistance training regimen should maintain bone and muscle mass. It has been demonstrated that aerobic exercise reduces fatigue. Those with mild to a moderate disability should participate in aerobic exercise for no less than 30 minutes twice weekly and practice strengthening exercises for major muscle groups twice weekly, according to the National Multiple Sclerosis Society’s recommendations for physical activity (Kalb et al., 2020). Exercises like these have been shown to help with fatigue, mobility, and health-related aspects of life for persons with MS. Therefore, practitioners and patients alike are urged to follow these carefully crafted recommendations (Kalb et al., 2020). Aerobic exercise training at a low to moderate activity can help MS patients with mild to moderate impairment improve their aerobic fitness and experience less tiredness.
Aerobic activity twice weekly for 10–30 minutes at a moderate intensity and weight training twice weekly for 1–3 sets of 8–15 repetitions maximum (RM) is the suggested exercise guidelines for MS, as stated in a brief review and synthesis (Kalb et al., 2020). However, more study is required to fully understand the advantages and training adaptations of aerobic and strength training, whether performed together or separately. Those with MS who participate in aquatic fitness programs report feeling better. It helps people with physical disabilities engage in social activities and enhances their overall health, energy, and emotional well-being. Patients with severe paresis of the lower extremities can nevertheless stand and move around with the help of aquatic training due to the diminished impact of gravity. According to a systematic review and Meta-Analysis, patients with multiple sclerosis may benefit from combining water therapy with traditional physical therapy (Kalb et al., 2020).
Targeted balance training can improve balance. Those who have trouble controlling their posture are more prone to fall. Multiple sclerosis patients often wobble more while they are standing stationary, react to postural changes more slowly, and move less close to their stability limits. Specific circumstances increase the danger of falling. The majority of studies on gait in MS reveal decreased gait speed, cadence, shorter strides, and joint mobility.
Hippotherapy, frequently known as horseback riding therapy, has been noted to improve health outcomes and the quality of life for patients with MS. It also assists them in regaining their equilibrium. A comprehensive study and meta-analysis of horseback riding’s effectiveness as a therapeutic intervention indicated that it had good physical and psychological advantages for those with neuromotor and physical impairments (Wallace et al., 2019). Those with multiple sclerosis who can walk benefit from horseback riding because of the sensory input and rhythmic forward and backward motion it provides. Posture and equilibrium are also enhanced.
There is some evidence that cognitive behavioral therapy (CBT) can help reduce fatigue in MS patients (Dobson & Giovannoni et al., 2019). Nevertheless, this benefit diminishes if medication is stopped. Referring the patient to a CBT expert is recommended for the most significant outcomes. In the short-term, cognitive behavioral therapy (CBT) can be an effective strategy for lowering mild depression in MS patients, which may positively influence the quality of life. People with multiple sclerosis benefit greatly from gait rehabilitation as part of their neurorehabilitation.
III. Ongoing Examination and Screening Procedures
To ensure an accurate diagnosis of MS, proper diagnostic testing and screening procedures are conducted to eliminate the possibility of any other diseases that share similar symptoms. Blood testing allows other differential illnesses that exhibit MS-like symptoms to be effectively ruled out. However, new tests are currently being advanced to faciliate in the diagnosis of MS by detecting definite biomarkers unique to MS (McGihley et al., 2021). A small amount of cerebrospinal fluid is taken from the spinal canal during a lumbar puncture and submitted to a lab for additional analysis. This sample may show abnormalities in MS-related antibodies. It can also rule out other possible causes of MS-like symptoms, such as an infection. The traditional spinal fluid test for MS has been slow and costly, but a novel antibody test may replace it.
Magnetic resonance imaging (MRI) is a scan that creates detailed images of the body by using strong magnetic fields. It has evolved into the most sensitive and noninvasive tool for examining the brain, spinal cord, or other related parts (Filippi et al., 2019). It is the imaging technique for confirming an MS diagnosis and tracking the disease over time. MRI can show the physical manifestations of MS, and a deeper understanding of the disease can be gained. Radiation is not used in MRI like in CT scans or traditional X-rays (Filippi et al., 2019). In contrast, magnetic resonance imaging (MRI) utilizes radio waves and magnetic fields to determine how much water different tissues contain. Myelin, the fatty layer that wraps around and shields nerve fibers, is impermeable to liquids. Fat loss occurs in regions where multiple sclerosis has damaged myelin. In addition, MRI scans aid doctors in monitoring a patient’s disease progression and determining the most effective treatment.
Consequently, the patient may be subjected to an evoked potential test, where the electrical impulses the nervous system generates in reaction to stimuli are recorded. Both visual and electrical stimuli can be used in an evoked potential test. Short electric signals are administered to nerves in the legs or arms as a moving visual pattern is observed. The speed with which information travels via your nerve pathways can be determined using electrodes.
The cornerstone of treatment for relapsing-remitting MS is disease-modifying medications. Some of the most common disease-modifying treatments include fingolimod, interferon-beta preparations, natalizumab, mitoxantrone, glatiramer acetate, and dimethyl fumarate (McGihley et al., 2021). After a definitive diagnosis has been made, prompt therapeutic interventions can begin. The decrease in MRI lesion activity is an intermediate goal. The avoidance of recurrent progressive MS is a long-term objective. Patient adherence and hazardous effects monitoring are the main concerns following treatment initiation.
Synthetic polypeptide combination glatiramer acetate may be a ligand for significant histocompatibility complex (MHC) components. Regulatory cells are induced, and activation is capped by binding. Mechanisms of neuroprotection and healing are also possible. The drug is administered subcutaneously. Potentially, resulting side effects may alter physical therapy interventions. These adverse effects include chest pain, joint pain, neck pain, tightness, muscle pain and aches, and a severe throbbing headache. They cause activity intolerance, and the patient may be unable to actively participate in physical therapy interventions such as physical exercise.
There are several potential modes of action for interferon-beta preparations. Interferon-beta may affect cytokine expression, aid blood-brain barrier repair, reduce matrix metalloproteinase expression, and modulate T- and B-cell activity (McGihley et al., 2021). Depending on the formulation, the administration might be subcutaneously or intramuscularly. The patient may experience flu-like symptoms and a temporary worsening of their current neurologic problems, which could impact physical therapy interventions.
Inhibiting leukocyte attachment with vascular endothelial cells, natalizumab is a humanized monoclonal antibody injected intravenously. This medication averts leukocytes from entering the brain and spinal cord (McGihley et al., 2021). Additionally, it produces minimal adverse effects. Common side effects of intravenous injection include mild headaches and flushing.
Inhibiting DNA restoration and RNA synthesis, mitoxantrone is a chemotherapy drug given intravenously. The mechanism of MS treatment may involve an impact on cellular and humoral immunity. Amenorrhea and alopecia are only two of the many side effects that have been reported. However, these do not have a severe adverse effect on the physical therapy interventions employed. Fingolimod is an immunomodulatory medication that can be taken orally and may affect T cell migration inhibition.
An attack from multiple sclerosis (MS) is when new symptoms or preexisting ones worsen. The central cause is chronic inflammation in the central nervous system. The intensity of these attacks varies from patient to patient, so treatment recommendations are chosen individually. Abortive therapies, or corticosteroids, such as glucocorticoids like prednisone and methylprednisolone, are widely utilized to manage relapses (McGihley et al., 2021). When dealing with severe relapses, these treatments should be tried first. They work by lowering inflammation and speeding up recovery from relapse by mimicking the effects of the preexisting glucocorticoid hormone cortisol.
Adrenocorticotropic hormone (ACTH) preparations have been purified. Patients who do not have an excellent response to or who cannot take corticosteroids may benefit from this treatment as an additional relapse management strategy. By increasing the body’s natural supply of cortisol and other adrenocortical hormones, ACTH products might mitigate inflammation and hasten the healing process following a relapse. Plasmapheresis can also be implemented. With this treatment, the liquid component of blood, called plasma, is removed and then restored (Hauser & Cree, 2020). It removes antibodies and other proteins that may be causing inflammation in people with MS. Those who do not respond well to corticosteroid treatment may also be candidates for this treatment.
V. Patient Goals and PT Goals
When it comes to patient care, a physical therapist is invaluable, whether at the diagnostic or treatment stage. The goals of PT include:
- Informing individuals about how physical therapy can keep them mobile, safe, and comfortable.
- Providing MS patients and their loved ones with access to informative materials
- Extensive evaluation and testing in physical therapy to determine starting points.
- Establishing reasonable goals and expectations while offering emotional support to determining current physical abilities and potential growth areas
- Assessments and a few follow-up sessions may be required to initiate care. To ensure exercise monitoring, adherence, and advancement, follow-up visits are not frequent (i.e., once a week or monthly for 3-5 visits).
- Establishing a physical activity and exercise program for the MS patient in light of their participation level, interests, and physical therapy assessment.
- Stressing the value of exercise in preventing disease and achieving one’s health goals
- Even when there are no changes in clinical status or radiographic evidence of disease progression, physical therapists should continue to track patients’ mobility.
- The physical therapist aids in keeping the patient motivated when things seem “excellent” when they may be less likely to exercise regularly.
- Physical therapy’s main goal is to recover function that has been lost before, during, or after a relapse.
- Due to weariness, the initial examination and evaluation may be shortened.
- Concern about how a relapse may affect the patient’s and their family’s day-to-day activities is natural. The physical therapist’s role is to offer positive reinforcement and practical encouragement.
- As their condition worsens, patients often require more assistive devices, including walkers, wheelchairs, and shower chairs. Patients and loved ones may have unfavorable reactions to these gadgets. The physical therapist has a duty to the patient and their family to advocate for the safe, effective, and prompt use of these devices. They’re more like “tools” for mobility than “obstacles,” ensuring one can get where they need to go home, at work, and in society without risk.
- The physical therapist emphasizes exercise and physical activity but now prioritizes activities differently to account for the patient’s changing skill level and the persistent problem of MS fatigue. The physical therapist is responsible for considering the patient’s condition’s physical, psychological, and social effects.
The greatest strategy to complete a good recovery is to set goals. The patient should have some goals for the conclusion of the physical therapy program before beginning treatment. The process of recovery, like setting goals, can be highly personalized. Thinking of the objectives concerning function and limitations can be helpful at times. Functional goals include:
- To be mobile enough to go directly from bed to bathroom
- To get back to work
- In order to get back to work without feeling tired
The patient can get through her routine with the support of these aims. Functions, or daily tasks, are at the center of these discussions. Her current limitations and the desired outcomes will determine the particular functional goals once rehabilitation is complete. Impairment goals refer to observable outcomes that may not be ideal at the outset of physical therapy. Some specific aims of impairment treatment are:
- Normalize equilibrium
- Restore the entire joint range of motion
- Increase the maximum strength of a muscle or muscle group.
- Reduce discomfort in a selected set of muscles or body parts.
VI. Plan of Care for the PT Diagnosis
Pelvic floor physical therapy is a method that employs physical therapy concepts to rehabilitate the pelvic floor muscles in a systematic, efficient, and safe manner. The treatment intends to increase pelvic floor muscle strength and function and reduce pain, muscle weakness, and dysfunction. A trained physiotherapist manipulates the rectus and vaginal muscles during treatment to increase their strength and efficiency (Wallace et al., 2019). If the muscles are tight and short, the therapist may stretch them; if they are weak and dysfunctional, they may be strengthened by resistance training.
The pelvic floor is made up of muscles, ligaments, and connective tissues that support the pelvic organs, help with libido and orgasm, and govern urination and bowel movements (Quaghebeur et al., 2021). These are supported by coordinated tissues that connect the pelvis, tailbone, and sacrum. These structures include the uterus, rectum, urethra, bladder, and vagina. They support healthy pelvic organ function, including urine and genitalia, maintaining good posture and breathing. Many painful and perhaps crippling symptoms might result from weak pelvic floor muscles (Quaghebeur et al., 2021).
Educating the patient is crucial throughout treatment. The patient’s understanding of their pelvic anatomy and the interdependence of its various parts are expanded. Patients are educated on the links between hygiene and symptom improvement. Instruction in pelvic floor exercises is also crucial. The patient can be educated on the relaxation and contraction of the pelvic floor muscles in conjunction with other muscles. They are also taught good breathing and timing techniques so they can get the most out of the workouts (Wallace et al., 2019)). The exercises aim to increase flexibility while also helping to stretch stiff muscles and strengthen weak ones. Restoring control of the pelvic floor function is one of the key goals of pelvic floor re-education.
After a thorough diagnostic and physical assessment, which may involve a manual pelvic or rectal examination, an individualized treatment plan is negotiated and agreed upon. Retraining of the pelvic floor muscles themselves, as well as physical treatment, bowel and bladder training, biofeedback, electrotherapy, education, and counseling, may all be a part of pelvic floor rehabilitation.
The goals of manual treatment for pelvic floor dysfunction are to reduce tension, improve flexibility, and lessen pain. The muscles, tendons, fascias, ligaments, nerves, and joints may be treated using internal vaginal or rectal procedures and exterior techniques. Electrostimulation of muscles can raise consciousness, remind overly weak pelvic floor muscles of their function, and aid in the muscles’ development and strengthening. The patient will be given a series of progressive exercises, physical therapies, and self-care strategies. The patient’s best chance at recovery and success lies in her willingness to actively participate in her rehabilitation, follow the recommendations, and make the necessary lifestyle changes. Home Workout Routine
Hence, biofeedback is a tool-assisted technique that gives patients real-time feedback on activating their pelvic floor muscles. Both overly-tense and under-used pelvic floor muscles can benefit from biofeedback training. Biofeedback activities, like the Kegel exercise, involve muscle tension and relaxation cycles. The pelvic floor muscles may gain greater neuromuscular and sensitivity control through biofeedback therapies.
VII. Plan of Care for the Medical Diagnosis
Disease modification, relapse control, and symptom management are at the center of multiple sclerosis care. Relapses are reduced, impairment is lessened, and symptoms are alleviated as part of the treatment process. Physical, mental, sensory, and bowel and bladder function should all be evaluated as part of a complete evaluation. Future neurologic examinations can be compared to the baseline functional assessment. For function assessment, evaluation frequency has not been properly investigated. The PCP is in charge of doing a preliminary evaluation of function and then continuing to watch for any changes.
In order to educate and counsel patients on the anticipated benefits and harmful effects of drug therapy, nurses must understand the mechanism of action of MS medicines. The PCP should be aware of how patient preferences and the complexity of drug regimens affect their patient’s ability to tolerate and comply with therapy. In addition, the PCP can help multiple sclerosis patients by advocating on their behalf to gain access to medication support services. The PCP needs to be informed of how well his patient is responding to treatment so that they may advocate for timely follow-up with the right members of the interdisciplinary team. PCPs caring for multiple sclerosis patients should look for and respond effectively to any signs of adverse drug reactions.
The PCP should examine the patient as needed for pain, dysesthesia, spasticity, loss of neuroprotective feeling, the risk of pressure ulcer development, triggers and alleviators, the efficacy of pharmacologic therapy, and the need for interdisciplinary team evaluation. The PCP also offers psychological solace and checks for signs of anxiousness. Inform the patient and family about the options for adjuvant therapy and surgical intervention; determine the patient’s openness to and preparedness for such therapies.
Hence, the PCP should be cognizant of, and evaluate for, comorbid conditions such as depression, drug side effects, pain, and sleep difficulties contributing to exhaustion. The function of temperature regulation in energy saving should be emphasized in patient education and counseling provided by the PCP. Also, the PCP needs to know when to give medications to maximize alertness and minimize disruptions to sleep. In addition, the PCP will need to pinpoint the operational impact of the patient’s reduced mobility and work with the multidisciplinary team to find ways to help them move as freely as possible, given their constraints. Physical activity is one of the therapeutic interventions that have been proved to improve mobility. Support treatment and therapy recommendations via patient and caregiver education. The PCP’s role is to promote security by stressing the importance of correct and safe usage of assistive technologies. Think about how having less mobility or more impairment can affect your mental health.
The primary care provider (PCP) is tasked with creating a bladder management plan in collaboration with the patient, care partner, and interdisciplinary team. Check for urinary dysfunction in every patient and track the long-term success of any behavioral or medical interventions. Help people learn to cope by encouraging them to talk about their symptoms, effects, and roles. Determine the presence of infection and aid in devising preventative measures against further infection, the development of stones, or a worsening of the neurologic condition.
Non-drug approaches to bowel management may include the following:
- Behavior management
- Including the establishment of a regular schedule
- Dietary instruction to reduce irritants and enhance fluid intake
- The addition of dietary fiber to foods that the patient can tolerate
- An assessment of the patient’s environment to determine the best placement of toilets and absorbent products, and biofeedback;
- Making use of one’s reflexes. The small intestine and stomach reflex are stimulated.
The PCP should develop an effective bowel management program with the patient, care companion, and interdisciplinary team. Examine the patient’s intestinal function and track the progress of any treatment or behavioral changes. It is essential to monitor the improvement of symptoms in response to treatment and the efficacy of drugs, keeping in mind that bowel therapies may require some time to become effective.
To help MS patients and their families follow the treatment plan, manage symptoms, and cope with a chronic disease, the PCP should take an evidence-based and well-being approach to teaching and counseling. The PCP must assess the patient’s cognitive and health literacy levels, among other things, to determine how best to tailor instruction.
In order to offer the best possible treatment for the patient, it may be necessary to refer them to specialists in various medical fields. The patient will be referred to doctors, nurses, and other medical professionals. To begin, “community nurse” describes any nurse who works outside a hospital setting. Community-based nurses fall into this category, including district nurses, community matrons, and practice nurses. They evaluate the patient’s condition, offer guidance on managing symptoms, and provide access to necessary assistance and devices. The patient will receive assistance from a counselor in coping with emotional difficulties, despair, and mood swings. Talking to a counselor is a great way to work through problems and obtain new perspectives. Dietitians are trained professionals that specialize in food and diet. The patient’s weight and vitamin D insufficiency may have contributed to the development of multiple sclerosis. As a result, the services of a dietician are essential for the purposes of instruction and supplementation. Hospital-based neurologists treat patients with neurological disorders. Some treat only multiple sclerosis, whereas others treat multiple sclerosis and other nerve-related disorders. They must be able to identify multiple sclerosis, prescribe disease-modifying treatments, and send patients to appropriate care centers. Neurologists owe an obligation to their patients to detail what will likely be a lengthy and involved diagnosis process, including a list of possible tests.
The patient should consult their primary care physician (PCP) if symptoms persist for more than 24 hours. She should talk to a nurse or physician if she cannot contact her primary care physician. Mild symptoms, such as numbness or tingling, may not require treatment, and even more, severe symptoms may be treatable outside of a hospital setting.
If she experiences symptoms that prevent her from eating, drinking, taking care of herself, or moving around, she should go to the hospital immediately or call 911. The inability to move or keep balance, severe pain, and vision loss caused by optic neuritis are all conditions that may necessitate hospitalization.
VIII. Patient Outcomes
- The patient will be able to identify their habits and external factors that lead to fatigue as well as strategies to maintain their desired activity level (D’ Amico et al., 2019).
- The individual will take part in the prescribed treatment.
- The patient will feel more energized and be able to pinpoint specific areas of weakness and care needs.
- The patient will show the skills and lifestyle changes necessary to provide for his or her self-care requirements adequately.
- The individual will actively participate in their education by seeking out knowledge, asking questions, and identifying personal and community resources that can help.
- The patient will express verbal confirmation of comprehension of the condition/disease mechanism and therapy.
- The individual will start following the treatment plan and making the required adjustments to their lifestyle.
D’Amico, E., Haase, R., & Ziemssen, T. (2019). Patient-reported outcomes in multiple sclerosis care. Multiple sclerosis and related disorders, 33, 61-66.
Dobson, R., & Giovannoni, G. (2019). Multiple sclerosis–a review. European Journal of Neurology, 26(1), 27-40.
Faka Schulte, A. (2020). Inflammatory activation of the kynurenine pathway: studies with lipopolysaccharides.
Filippi, M., Preziosa, P., Banwell, B. L., Barkhof, F., Ciccarelli, O., De Stefano, N., … & Rocca, M. A. (2019). Assessment of lesions on magnetic resonance imaging in multiple sclerosis: practical guidelines. Brain, 142(7), 1858-1875.
Hauser, S. L., & Cree, B. A. (2020). Treatment of multiple sclerosis: a review. The American Journal of medicine, 133(12), 1380-1390.
Kalb, R., Brown, T. R., Coote, S., Costello, K., Dalgas, U., Garmon, E., … & Motl, R. W. (2020). Exercise and lifestyle physical activity recommendations for people with multiple sclerosis throughout the disease course. Multiple Sclerosis Journal, 26(12), 1459–1469.
Makhani, N., & Tremlett, H. (2021). The multiple sclerosis prodrome. Nature Reviews Neurology, 17(8), 515-521.
McGinley, M. P., Goldschmidt, C. H., & Rae-Grant, A. D. (2021). Diagnosis and treatment of multiple sclerosis: a review. Jama, 325(8), 765-779.
Quaghebeur, J., Petros, P., Wyndaele, J. J., & De Wachter, S. (2021). Pelvic-floor function, dysfunction, and treatment. European Journal of Obstetrics & Gynecology and Reproductive Biology, 265, 143-149.
Wallace, S. L., Miller, L. D., & Mishra, K. (2019). Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Current Opinion in Obstetrics and Gynecology, 31(6), 485–493.