Physiotherapy management of acute transverse myelitis in a pediatric patient in a Nigerian hospital: a case report

Transverse myelitis (TM) is a rare neurological disorder of the spinal cord. It is caused by inflammation and damage of the myelin sheath of the neurons of the spinal cord across one or more spinal segments. This causes a disruption in the passage of nervous signals leading to motor, sensory, and autonomic dysfunction [1]. According to the National Institute of Neurological Disorders and Stroke [2], it is characterized by a marked sensory disturbance at a defined sensory level. The cause may be idiopathic or it may be secondary to inflammatory processes from infections and immune system disorders [3]. It can appear as the first symptom in conditions such as multiple sclerosis and neuromyelitis optica [1].

According to the Transverse Myelitis Consortium Working Group [4], acute transverse myelitis affects about 1–4 per million people each year, with peak age ranges of 10–19 years and 20–39 years. The incidence of acute TM in children is approximately 0.2 per 100,000 per year [5‐7]. In Nigeria, Owolabi et al. [8] found a 13.1% prevalence of transverse myelitis in 98 patients with nontraumatic spinal cord injury in Aminu-Kano Teaching Hospital, Kano Nigeria.

The standard medical treatment for acute transverse myelitis is intravenous steroids [6, 9, 10], and prognosis varies among patients. Approximately a third of patients demonstrate either complete recovery, mild residual deficits, or severe disability [11, 12].

Calis et al. [13] and Krishnan et al. [14] suggest that physical rehabilitation should be incorporated in the management of TM. However, the physiotherapy management of transverse myelitis symptoms remains insufficiently studied, with a dearth of studies in this area. Calis et al. [13], Heggie [15], Schrader [16], and Buchanan Wilkerson and Huang [10] have all published case reports on the role of physiotherapy in the management of acute TM. They reported improvements in clinical and functional outcomes, such as spasticity, range of motion, functional independence, ambulation, and quality of life. These studies were carried out among Turkish [13], Korean [15], and American [10, 16] patients. Currently, there does not appear to be any studies on the physiotherapy management of acute TM in Africa, and Nigeria specifically, despite the significant prevalence of TM in Nigeria [8]. Therefore, this case report highlights the physiotherapy management of a case of acute transverse myelitis in a Nigerian teaching hospital.

This case report presents the physiotherapy evaluation and rehabilitation of a 17-year-old male with acute transverse myelitis. The physiotherapy plan of care and treatment was in collaboration with the patient and caregivers (parents). There is dearth of clinical studies on the physiotherapy management of acute transverse myelitis, however, available evidence suggest that the treatment strategy needs to be based on activity, with emphasis on impairment [10, 13]. Physiotherapy approaches need to incorporate functional tasks and movements into the patient’s exercise programmes. These include passive and active range of movement exercises, strengthening exercises, joint mobilizations, and neuromuscular reeducation [10, 17].

In this case report, the treatments were tailored in line with the patient’s symptoms. Certain symptoms needed to improve first to allow other symptoms to be worked on. For example, the frequent muscle spasm and jerking of the lower limbs needed to be brought under control to pave way for the normalization of the muscle tone and improvement of the joint range of movement. These in turn allowed the weak muscles to be strengthened and functional activities to be retrained. Hence, the patient’s treatment timeline and procedures were systematic.

The patient showed tremendous improvement in his symptoms over 3 weeks. He recovered significantly from the severe muscle spasm and frequent jerking in less than 7 days. Muscle hypertonicity and spasticity improved significantly within 14 days, while his muscle strength and functional status were almost normal at discharge. The influence of physiotherapy intervention on the rate of progression of acute transverse myelitis is yet to be studied using high-evidence research methods, such as randomized controlled trials and longitudinal studies. In the case of our patient, we cannot establish if it was physiotherapy in part,or alone that improved his condition. However, it improved his psychological health and outlook, as subjectively reported by the patient. The patient was a young boy and a fresh secondary school leaver. He was vibrant and led a good social life. He kept a good number of friends with whom he performed his leisure activities, including swimming and gym workouts. Then, suddenly, he became almost completely dependent in most of his activities of daily living. He was also concerned about the potential impact of his condition on his chances of attending university. Our treatment pattern encouraged him to be actively involved in his recovery, and this boosted his psyche.

The patient’s level of functional independence at discharge suggested that he was, at least, in the top one-third of people with acute transverse myelitis that recover most of their function following the resolution of the inflammation [13, 15]. Of great commendation was the motivation and complete effort that he brought into every treatment session. This likely contributed immensely to his recovery. He transferred the same motivation and effort into his outpatient and home physiotherapy programmes. The patient’s age might also have proven a huge factor in his recovery.

The limitations of this report include the delay in conducting the MRI, which could have made it impossible to detect the spinal cord inflammation. This delay, in addition to the drug treatment already commenced, could have made it difficult to outrightly diagnose transverse myelitis from the MRI. This could have been avoided if the MRI was conducted earlier when the symptoms started, before the drug treatments commenced. Scotti and Gerevini [18] reported that up to 40% of cases of TM have no findings on MRI. However, no specific reasons were given for such occurrence. Another limitation of this report is the same as noted in Calis et al. [13] and Heggie [15], which is the uncertainty concerning how much of the improvement in the patient was strictly due to the decreasing spinal cord inflammation. The physiotherapy management was delivered concurrently with other pharmacological treatments, such as the administration of antibiotics, corticosteroids, and muscle relaxants. None of the previous studies, including that by Calis et al [13] used a control group. The use of a control group would have been necessary to differentiate between the direct effect of physiotherapy interventions and other medical and pharmacological interventions, such as the administration of antibiotics, corticosteroid, muscle relaxants, and plasmapheresis.

However, an early report from a pilot study by Ratchford et al. [19] on multiple sclerosis, a related central nervous system inflammatory disease, has shown the positive effects of physiotherapy on spinal inflammation [15]. The study showed that cycling with functional electrical stimulation correlated with decreased inflammatory markers in the patient’s cerebrospinal fluid over 6 months. However, the small size of the sample used (four patients) affects the generalizability of the study, hence no definite conclusion could be drawn. Therefore, there is a need for further research that aims to determine whether physiotherapy could play any role in decreasing inflammation of the central nervous system.

In conclusion, physiotherapy management and interventions, when combined with other medical and pharmacological interventions, are effective in the management of the symptoms and complications of acute transverse myelitis. Early presentation in the health care facility improved the chances of recovery. Furthermore, an early referral to physiotherapy may have improved the prognosis and the clinical outcomes of the patient.

Due to the rarity of this condition in this population, this case was presented at the physiotherapy department, University of Port Harcourt Teaching Hospital after consent was obtained from the patient’s parents. The patient and his mother were invited to the seminar to give their perspective on the treatment they received from the physiotherapy team. The mother expressed her satisfaction with the manner with which the physiotherapy team handled her son’s case. Consent to publish her son’s case was sought thereafter, and she signed a written informed consent. She was assured that no identifying information regarding her son would be published.