This document discusses neurosyphilis, a sexually transmitted disease caused by Treponema pallidum that affects the nervous system. It describes four clinical types of neurosyphilis: asymptomatic neurosyphilis, meningovascular neurosyphilis, Tabes dorsalis, and general paralysis of insane. For each type, it outlines the characteristic symptoms, areas of the nervous system affected, and typical progression. The document also covers investigations, medical management focusing on penicillin treatment, and principles of physiotherapy management including assessment, goals, and specific plans and exercises.

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Neurosyphilis and
its Physiotherapy
Management
Muskan Rastogi
Bpt

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INTRODUCTION
 Neurosyphilis is a sexually transmitted disease that affects the
nervous system by Treponema pallidum.
 It has been becoming uncommon disease after the introduction
of modern broad-spectrum antibiotics like penicillin.

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CLINICAL TYPES
 Asymptomatic neurosyphilis
 Meningovascular neurosyphilis
 Tabes Dorsalis
 General paralysis of insane

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1.ASYMPTOMTIC NEUROSYPHILIS
 It is manifested by a reactive non-treponemal CSF
serology(VDRL Test)
 There will be no signs and symptoms of focal neurological
disturbances
 The CSF usually reveals elevated protein levels, lymphocytic
pleocytosis and glucose levels

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2. MENINGOVASCULAR
NEUROSYPHILIS
 It occurs in the second stage of syphilis and effects the meninges and vessels of the
brain.
 Syphilitic endateritis causes infarction which is clinically similar to stroke.
 The luminal narrowing predisposes to cerebrovascular thrombosis, ischemia and
infarction
 The most common artery involved is middle cerebral artery
 The clinical manifestations include headaches, vertigo, insomnia and personality
disorders.
 If the base of the brain is involved, cranial nerve palsies can be evident.
 There may be formation of leptomeningeal granulomas which are avascular in nature
called gumma.

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3. TABES DORSALIS
 It is a slowly progressive parenchymatous degenerative disease involving the
posterior columns and posterior roots of the spinal cord.
 Symptoms include loss of pain sensation, loss of peripheral reflexes, impairment of
vibration and joint position sense and ataxia which is progressive.
 Bladder incontinence and loss of sexual function are common.
 15% of patients experience episodes of excruciating epigastric pain with
associated nausea and vomiting.
 These are 3 stages of Tabes dorsalis 1. Preataxia 2. Ataxia 3. Paralysis
 There will be wide based gait with slapping.
 Charcot joints and trophic ulcers develop in later stages.
 The pupils are bilaterally small and fail to constrict but demonstrate normal
constriction to accommodation

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4. GENERAL PARALYSIS OF INSANE
 It is commonly referred as dementia paralytica
 It occurs approximately 20-30 years after the initial exposure to Treponema pallidum.
 It represents a chronic progressive frontotemporal meningoencephalitis with resultant
ongoing loss of cortical functions.
 There will be insidious onset of psychiatric symptoms of general paresis
 These include loss of interest in work, memory lapse, irritability, unusual giddiness,
apathy, social withdrawal.
 Later stages, the symptoms of schizophrenia, euphoric mania, paranoia, toxic psychosis.
 After approximately 5 years of onset, there will be convulsions.
 Abnormal gait, paresthesias, lightening pains of extremities, loss of proprioception,
Romberg sign positive.

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INVESTIGATIONS
 CSF analysis
 Serological tests
 VDRL test
 Treponomal tests
 Non-treponomal tests
 Radiological examination
 Electrodiagnostic tests

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MEDICAL MANAGEMENT
Penicillin G, administered parenterally, is the preferred drug for
treating persons in all stages of syphilis.

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PRINCIPLES OF PHYSIOTHERAPY
ASSESSMENT
The principles of assessment follow the routine neurological assessment with emphasis
on the following:
 Take history of onset of general or constitutional symptoms like headache, fever,
fatigue, weakness, and dizziness.
 Check the patient about the symptoms like pain, redness in eyes, loss/double vision,
photophobia, ringing of bells I ears, loss of hearing
 Check the musculoskeletal symptoms like neck pain, stiffness, muscle weakness.
 Enquire the patient about the neurological symptoms like headache, dizziness,
muscle weakness, confusion, loss of consciousness, seizures, difficulty in speaking
etc.

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 Obtain the clear personality changes, if any, from family members of the patient.
 Assess the cranial nerves to identify the cranial nerve palsies
 Perform a clear and accurate sensory examination. Usually there will be loss of superficial
and cortical sensations.
 Motor examination reveals the muscle weakness. In case of meningococcal neurosyphilis,
there will be motor dysfunction like stroke-spasticity, synergies, loss of voluntary control
etc.
 Examine the reflexes-hyperreflexia
 Nuchal rigidity testing: Assess for meningeal inflammation by following tests:
Brudzinski’s sign and Joint accentuation maneuver
 Assess for neurological bladder symptoms
 ADL assessment which shows diminished capabilities
 Co-ordination and balance is impaired
 On examination of gait, there will be abnormal gait pattern usually ataxic gait is seen.

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PHYSIOTHERAPY MANAGEMENT
 AIMS
 To educate the patient abouts STD’s.
 To improve the muscle power
 To improve cardiovascular and respiratory endurance
 To improve balance and equilibrium
 To improve co-ordination
 To prevent contractures and deformities
 Early ambulation
 Improve the functional capacity of the patient

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 Plans
 Educate patient on the safety measures and precautions to prevent STD’s
 Advise the patient to avoid multiple sex partners.
 All strengthening exercises are trained depending upon muscle power of the patient
 Proper positioning to prevent contractures and deformities
 Balance and Equilibrium exercises.
 Frenkel’s exercises in various positions
 Deep breathing exercises like pranayama, VMT, spirometry to improve ventilatory
effort.
 Aerobics to improve cardiovascular endurance
 Cycling, swimming exercises promotes endurance
 Early ambulation, if needed suitable supports or splints are advised.