Physiotherapy management of transverse myelitis : A case study.ppt

A case study on the physiotherapy management of transverse myelitis by Oluwadamilare Akinwande

1. PHYSIOTHERAPY MANAGEMENT OF TRANSVERSE MYELITIS: A CASE STUDY PRESENTED BY OLUWADAMILARE JOSHUA AKINWANDE (PT) IN PHYSIOTHERAPY DEPARTMENT AT STATE HOSPITAL, ABEOKUTA.

2. OUTLINE INTRODUCTION EPIDEMIOLOGY MECHANISM OF INJURY SUB-CLASSIFICATION CLINICAL PRESENTATION DIAGNOSTIC PROCEDURES MEDICAL MANAGEMENT REHABILITATION CASE STUDY REFERENCES

3. INTRODUCTION Myelitis is a neurological disorder of the spinal cord that is caused by inflammation (National Institute of Neurological Disorders and Stroke [NINDS],2019). The term “ transverse” was first added to “myelitis” in the case report of an acute inflammatory spinal cord pathology complicating a pneumonia ( Suchett -Kaye, 1948). The term “transverse” in this case referred to the common clinical finding of a band-like horizontal area of altered sensation usually at dermatomal level of the lesion within the cord (Kerr, 2010). In most cases, transverse myelitis (TM) usually presents acutely ( though it presents sub-acutely at times). For this reason, it is often used interchangeably with the term “ acute transverse myelitis” (West, 2013).

4. EPIDEMIOLOGY Acute transverse myelitis has an estimated incidence of 1.34 to 4.6 per million (Berman, Feldman, Alter, Zilbar & Kahana , 1981 ; Jeffery, Mandler & Davis, 1993) but has been reported to be as high as 3.1 per 100,000 (Klein et al., 2010). There does not seem to be a familial or ethnic predisposition for acute transverse myelitis and there is no evidence of geographic variation in its incidence (Bhat, Naguwa , Cheema & Gershwin, 2010). A peak in incidence rates i.e. the number of new cases per year appears to occur between 10-19 years and 30- 39 years (NINDS, 2019).

5. MECHANISM OF INJURY The mechanism of injury is inflammation of the spinal cord resulting in the damage of the myelin sheath of the nerves ( Physiopedia , 2020). The cause of the inflammation and the extent of damage to the spinal nerve fibres are unknown in most cases. A number of conditions appears to cause transverse myelitis namely: Demyelinating disorders Viral infections Bacterial infections Fungal infections Parasites Other inflammatory disorders (NINDS, 2019).

6. SUB-CLASSIFICATION OF TRANSVERSE MYELITIS Transverse myelitis can either be acute (developing over hours to several days) or sub-acute (usually developing over one to four weeks) (NINDS, 2019). Transverse myelitis is commonly divided into two subgroups on the basis of the extent of spinal cord involvement namely: Acute complete transverse myelitis (ACTM) which is an inflammatory process of the spinal cord resulting in symmetric moderate or severe loss of function distal to the level of affectation. Acute partial transverse myelitis (APTM) which is characterized by incomplete or patchy involvement of at least one spinal segment with mild to moderate weakness, asymmetric or dissociated sensory symptoms and occasionally bladder involvement (Scott, Frohman, De Seze , Gronseth & Weinshenker , 2011).

7. CLINICAL PRESENTATION TM is characterized clinically by acutely or sub-acutely developing symptoms and signs of neurological dysfunction in motor, sensory and autonomic nerves and nerve tracts of the spinal cord. Weakness is described as a rapidly progressive paraparesis starting with the legs and occasionally progresses to involve the arms as well. Flaccidity may be noted initially with gradually appearing pyramidal signs by the second week of the illness. A sensory level can be documented in most cases. The most common sensory level in adults is the mid-thoracic region, though children may have a higher frequency of cervical spinal cord involvement and a cervical sensory level.

8. Autonomic symptoms consist variably of increased urinary urgency, bowel or bladder incontinence, difficulty or inability to void, incomplete evacuation or bowel constipation (Krishnan, Kaplin , Deshpande, Pando & Kerr, 2004). Pain may occur in the back, extremities or abdomen (Krishnan et al., 2004). Many individuals also report experiencing muscle spasms, a general feeling of discomfort, headache, fever, and loss of appetite, while some people experience respiratory problems. Other symptoms may include sexual dysfunction and depression and anxiety caused by lifestyle (NINDS, 2019). The segment of the spinal cord at which the damage occurs determines which parts of the body are affected. Damage at one segment will affect function at that level and below (NINDS, 2019).

9. DIAGNOSTIC PROCEDURES Transverse myelitis is diagnosed by taking a medical history and performing a thorough neurological examination. The tests that can indicate a diagnosis of transverse myelitis and rule out or evaluate underlying causes include : MRI Blood test Lumbar puncture If none of these tests suggests a specific cause, the person is presumed to have idiopathic transverse myelitis. In occasional cases, initial testing using MRI and lumbar puncture may show normal results but may need to be repeated in 5-7 days (NINDS, 2019).

10. DIAGNOSTIC CRITERIA FOR TRANSVERSE MYELITIS (adopted from Frohman & Wingerchuk , 2010).

11. FEATURES OF COMMON MYELITIS SYNDROME ON NEUROIMAGING (adopted from Frohman & Wingerchuk , 2010)

12. MEDICAL MANAGEMENT The goals of medical management during the acute phase of myelitis are to halt the progression and initiate the resolution of the inflammatory spinal cord lesion, thereby speeding clinical recovery (Frohman & Wingerchuk , 2010). These goals may be achieved via: Appropriate antibiotic or antiviral drugs Intravenous steroids Plasmapheresis Other immunosuppressive agents such as intravenous Ig, Cyclophosphamide, Rituximab, Azathioprine etcetera (NINDS, 2019 ; West, 2013).

13. REHABILITATION IN TRANSVERSE MYELITIS MANAGEMENT Individuals with lasting neurological defects from transverse myelitis typically consult with a range of rehabilitation specialists, who may include physiatrists, physical therapists, occupational therapists, vocational therapists , and mental health care professionals (NINDS, 2019). The principles of rehabilitation must be applied in the early and chronic phases after transverse myelitis ( Calis , Kirnap , Calis , Mistik & Demir , 2011). The aim of rehabilitation in transverse myelitis are : increasing the patient’s strength and endurance, improving co-ordination, reducing spasticity and muscle wasting in paralyzed limbs and regaining greater control over bladder and bowel function ( Calis et al., 2011).

14. PT ROLE IN REHABILITATION OF PATIENTS WITH TM The PT treatment needs to incorporate functional tasks and movements into exercise programs, including passive and active ROM exercises, strengthening exercises , joint mobilizations as necessary, and neuromuscular re-education (Buchanan, Wilkerson & Huang, 2018). Fatigue is one of the most common presentations in people with TM. As a result of this, education including energy conservation techniques need to be emphasized during PT treatment. In addition, complex functional activities may not be appropriate for patients with TM, because the patients may become fatigued quickly. When prescribing therapeutic exercise, physical therapists may need to break down one functional movement into several actions , as well as instruct patients how each single exercise would be functionally important and relevant in tasks of daily living (Buchanan et al., 2018).

15. CASE STUDY Case Description Patient (Pt) is a 25-year-old female with a previous medical history of hospitalization as a result of Typhoid Fever and a previous surgical history of lumpectomy. Pt started receiving treatment for back pain at Olikoye Hospital, Asero ten days after being delivered of a baby via Caesarean Section that involved general anaesthesia . Pt was later taken to a private hospital when her condition was not improving before she was eventually referred to Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) where various tests were carried out to determine the cause of her ailment. She was managed by a team of neurologists and physiotherapists at OAUTHC before she was later discharged and advised to commence physiotherapy management in Abeokuta. She reported in this facility 13/52 ago presenting with weakness of the bilateral upper limbs (ULs) and lower limbs (LLs), neck pain and stiffness, back pain and sensory disturbance in the hands as primary complaints.

16. Examination On examination, the Head and Neck presented with : ( i ) absence of facial asymmetry (ii) pain in the neck posteriorly (iii) limited active range of motion of the neck Thorax and Abdomen presented with : ( i ) weak trunk muscles (ii) impairment of sensation below the abdomen whereby Pt was only sensitive to deep touch below the ribs.

17. Upper Limbs presented with : ULs Variables Right UL Left UL Grip Strength Fair Good Range of Motion Complete Complete Muscle Tone Slightly increased Slightly Increased Muscle Bulk Slightly reduced Slightly reduced Sensation Intact Intact Pain/Discomfort Present in the shoulder and palm Present in the shoulder and palm

18. Lower Limbs presented with: LLs Variables Right LL Left LL Muscle Bulk Reduced Reduced Sensation Impaired Impaired Passive Range of Motion Complete Complete Gross Muscle Power Muscle Tone Reduced Reduced

19. Pelvis and Perineum presented with : ( i ) bladder{urinary} incontinence (ii) bowel {fecal} incontinence. Functional Assessment : Pt was dependent in all activities of daily living (ADL) except feeding which she carried out using her left hand. Clinical Impression : The results of the various blood tests, imaging test (MRI studies) and the CSF studies are suggestive of Transverse Myelitis.

20. Intervention The primary goals of treatment were to : Improve muscle strength of the ULs and LLs Improve functional ability Promote independence To achieve the aforementioned goals, the treatment regimen consisted of : Passive movement/Proprioceptive neuromuscular facilitation to all the limbs of the body Soft tissue massage with topical gel to the painful parts of the body Tactile stimulation to the lower limbs Reciprocal pulley exercise Trunk strengthening exercise Home exercise program.

21. Pt was reviewed 2 weeks after the commencement of the treatment regimen. The following changes were observed : Poor grip strength in the ULs bilaterally Reduction in the muscle tone of the ULs bilaterally Gross muscle power of two+ (2+) in the right UL and just two (2) in the left UL. The lower limbs withdrew from painful stimulus. As a result of the deterioration of Pt’s grip strength, she could no longer feed herself. Therefore, she became dependent in all ADL. PT intervention continued by implementing the treatment regimen.

22. After the sixth treatment session, some treatment techniques/approaches have been included in the treatment regimen. These techniques/approaches include standing re-education (within parallel bars) using back slabs and thoracolumbar jacket, resistance exercise to the ULs muscles using sand bags (1kg, 1.5kg, 2kg), bilateral static gluteal contraction, rolling from supine to prone lying and vice versa, weight bearing exercise to the ULs.

23. After twenty-two ( 22) treatment sessions, the outcomes are: Gross muscle power of four (4) in the ULs bilaterally Slight improvement in the grip strength bilaterally (left > right) Limitation in the active range of motion of the neck and the neck pain have resolved The pain in the bilateral shoulders has resolved Trunk muscles strength has improved Complete passive range of motion is still maintained in the lower limbs Increase in the muscle tone of the LLs bilaterally Gross muscle power of the LLs remains 0 bilaterally The LLs are only sensitive to painful stimulus Urinary incontinence and fecal incontinence still persist Pt is still dependent in ADL.

24. REFERENCES Berman, M., Feldman,S ., Alter,M ., Zilber , N., & Kahana , E. (1981). Acute transverse myelitis: Incidence and etiologic considerations. Neurology 31 (8), 966-971. Bhat, A., Naguwa , S., Cheema, G., & Gershwin, M. E. (2010). The epidemiology of transverse myelitis. Autoimmun Rev , 9 (5), 395-399. Buchanan, A., Wilkerson, K. J., & Huang, H. H. (2018). Physical therapy for transverse myelitis: A case report. J Nov Physiother Rehabil , 2 , 015-021. Calis , M., Kirnap , M., Calis , H., Mistik , S., & Demir , H. (2011). Rehabilitation results of patients with acute transverse myelitis . Bratisl Lek Listy , 112 , 154-156. Frohman, E. M., & Wingerchuk , D. M. (2010). Transverse myelitis. N Eng J Med , 363 (6).

25. Jeffery, D. R., Mandler , R. N., & Davis, L. E. (1983). Transverse myelitis: Retrospective analysis of 33 cases, with differentiation of cases associated with multiple sclerosis and parainfectious events. Arch Neurol , 50 (5), 532-53. Kerr, D. (2010). The history of transverse myelitis: The origins of the name and the identification of the disease . Retrieved from http:// www.myelitis.org/history.htm Klein, N. P., Ray, P., Carpenter, D., Hansen, J., Lewis, E., Fireman, B., … Baxter, R. (2010). Rates of autoimmune diseases in Kaiser Permanente for use in vaccine adverse event safety studies. Vaccine, 28 (4), 1062-1068. Krishnan, C., Kaplin , A. I., Deshpande, D. M., Pardo, C. A., & Kerr, D. A. (2004). Transverse myelitis: Pathogenesis, diagnosis and treatment. Front Biosci , 9 ,1483-1499 . National Institute of Neurological Disorders and Stroke. (2019). Transverse myelitis fact sheet . Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Transverse-Myelitis-Fact-Sheet

26. Physiopedia . (2020). Transverse myelitis . Retrieved from https://www.physio-pedia.com/Transverse_Myelitis Scott, T. F., Frohman, E. M., De Seze , J., Gronseth , G. S., & Weinshenker , B. G. (2011). Evidence-based guideline: C linical evaluation and treatment of transverse myelitis . Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology , 77 (24), 2128-2134. Suchett -Kaye, A. I. (1948). Acute transverse myelitis complicating pneumonia: R eport of a case. Lancet , 2 (6524), 417 . West, T. M. (2013). Transverse myelitis: A review of the presentation, diagnosis and initial management.