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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 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. 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. 3 Cleveland Clinic. Obtained from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/multiple_sclerosis/ on 8/21/16. 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. 5 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 7/29/16. 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. 7 RSNA. Obtained from https://www2.rsna.org/timssnet/media/pressreleases/14_pr_target.cfm?ID=758 on 8/24/16. 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 9 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 7/21/2016. 10 Obtained from CMSC. CMSC INforMS Newsletter on 7/19/2016. 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. 12 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 25. 13 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 35. 14 Neurology. Obtained from http://www.neurology.org/content/84/21/2185.full on 7/29/2016. 15 Advances in Multiple Sclerosis Primer, Buckle, G J, et all. CMSC. Page 62. 16 Photo obtained from Restorative Therapies website on 8/22/2016. 17 Photo obtained from Beckerorthopedic website on 8/11/16. 18 Photo obtained from Alinker website on 8/9/16. 19 Photo obtained from Bioness website on 8/24/16. 20 National Multiple Sclerosis Society. Obtained http://www.nationalmssociety.org on 8/05/16. 21 Photo obtained from http://rewalk.com/rewalk-rehabilitation/ on 8/24/2016. 22 Obtained from the National MS Society Magazine website http://www.momentummagazineonline.com/demystifying-mris/ on 8/24/2016. 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!