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:
i. Demyelinating disorders
ii. Viral infections
iii. Bacterial infections
iv. Fungal infections
v. Parasites
vi. 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:
i. 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.
ii. 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:
i. MRI
ii. Blood test
iii. 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:
i. Appropriate antibiotic or antiviral drugs
ii. Intravenous steroids
iii. Plasmapheresis
iv. 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 0 0
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 :
i. Improve muscle strength of the ULs and LLs
ii. Improve functional ability
iii. Promote independence
To achieve the aforementioned goals, the treatment regimen consisted of :
i. Passive movement/Proprioceptive neuromuscular facilitation to all the limbs of
the body
ii. Soft tissue massage with topical gel to the painful parts of the body
iii. Tactile stimulation to the lower limbs
iv. Reciprocal pulley exercise
v. Trunk strengthening exercise
vi. Home exercise program.

21. • Pt was reviewed 2 weeks after the commencement of the treatment regimen. The
following changes were observed :
i. Poor grip strength in the ULs bilaterally
ii. Reduction in the muscle tone of the ULs bilaterally
iii. Gross muscle power of two+ (2+) in the right UL and just two (2) in the left
UL.
iv. 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:
i. Gross muscle power of four (4) in the ULs bilaterally
ii. Slight improvement in the grip strength bilaterally (left > right)
iii. Limitation in the active range of motion of the neck and the neck pain have
resolved
iv. The pain in the bilateral shoulders has resolved
v. Trunk muscles strength has improved
vi. Complete passive range of motion is still maintained in the lower limbs
vii. Increase in the muscle tone of the LLs bilaterally
viii.Gross muscle power of the LLs remains 0 bilaterally
ix. The LLs are only sensitive to painful stimulus
x. Urinary incontinence and fecal incontinence still persist
xi. 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: Clinical 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:
Report of a case. Lancet , 2(6524), 417.
• West, T. M. (2013). Transverse myelitis: A review of the presentation, diagnosis and
initial management.