Características clínicas e perfil de funcionalidade em indivíduo acometido pela esclerose múltipla: um estudo de caso

Abstract

Introduction: Multiple sclerosis (MS) is a chronic and progressive autoimmune disease that affects the central nervous system. Among neurodegenerative disorders, it is one of the leading causes of neurological disability in young adults. Despite advances in care and rehabilitation, little is discussed about the functionality profile of those affected by MS and how this information is important to guide strategies for physiotherapeutic interventions. Objective: This case study aims to describe the functionality profile of a patient with Multiple Sclerosis who was attended to at the outpatient clinic of the University Hospital (HU) of the Federal University of Amapá (UNIFAP). Methodology: The evaluation involved performing neurological assessment procedures and complementary examinations. To describe the functionality profile, the brief Core Set for MS from the International Classification of Functioning, Disability and Health (ICF) was used. Results: The evaluation identified severe chronic pain, weakness in the lower limbs associated with spastic hypertonia with clonus and hyperreflexia, along with significant gait impairment. In terms of activity and participation, the patient experiences difficulty in performing daily tasks and maintaining relationships. Family support and access to health services serve as facilitating factors. Discussion: In light of these findings, identifying the functionality profile of an individual with MS is necessary to achieve personalized and multidisciplinary approaches. Conclusion: A detailed evaluation using the ICF can provide valuable information for the development of more effective and individualized interventions, especially within the context of physiotherapy.