202 Physiotherapy in Neuro-conditions

• Proper positioning of the patient is necessary because once the

limbs become weaker and emaciated it becomes increasing
difficult to maintain the upright position. This difficulty is noted
in standing, sitting in wheelchair or sitting in bed hence proper
positioning is necessary. In order to minimize the effect of gravity
on the body the patient should be inclined back from the vertical.
Assistance of pillows is necessary for providing him with
comfortable position.
• Psychological counseling is very essential to prevent the patient
from going into a state of depression and to keep his motivation
level high.
Some therapist believes in maintaining the muscle property by
giving stimulation which is controversial and is not recommended
by the author.

TRANSVERSE MYELITIS
Transverse myelitis is an acute or subacute monophasic usually
inflammatory disorder of the spinal cord affecting considerable
extent transversely but longitudinally limited to 1 or 2 segments of
the spinal cord.

Etiology
It is a postinfectious disorder of the spinal cord that is seen following
an episode of influenza, mumps, measles or infections caused by
Epstein-Barr virus. However the disease is not obvious at the time
of infection but occurs as the infection tapers off. It can occur after
infection like smallpox, rabies, etc.

Pathogenesis
It is not a result of direct effect of virus on the spinal cord but is an
autoimmune response of the body which gets provoked by infection.

Pathology
There is affection of white as well as gray matter. The spinal cord
appear edematous, hyperemic and infiltrated by inflammatory cells.

Clinical Features
• The onset is usually acute or subacute
• Disease usually starts either at back or neck area and is usually
localized.
 Ch 9: Spinal Cord Diseases 203

• The spine becomes very tender around the affected area

• Sensory loss: The person may have either altered sensation like
paresthesia or loss of sensation which begins in the distal part of
the leg and ascends upwards similar to the one in GBS. However
unlike GBS there is a sensory level, below which there is
completed loss of sensation and above the lesion there is normal
sensation. Between this normal and abnormal zone there may
be a zone of hypersensitivity in some patients.
• Motor loss: The motor symptoms usually is similar to that in acute
traumatic paraplegia with a stage of spinal shock during which
the tone is lost and there is areflexia but after some days of spinal
shock the tone gradually begins to build up and the reflexes
reappear. The babinski sign also becomes positive in the patient
at this stage. In case Babinski sign fails to become positive then it
indicates necrosis involving multiple segments.
• Sphincter disturbances: During the stage of spinal shock there is
atonic bladder but after the stage of spinal shock the patient has
automatic type of bladder if the lesion is above the spinal reflex
center for micturition.

Differential Diagnosis
• Multiple sclerosis
• Devic’s syndrome which starts with optic neuritis
• Systemic lupus erythematosus
• Behcet's syndrome.
The disease should be distinguished from the above conditions
which is done as under:

Multiple Sclerosis
The distinguishing character are remission and exacerbations,
affections of more than two areas of CNS and also involvement of
optic nerve.

Devic’s Syndrome
This is also called as Neuromyelitic optica. It starts with bilateral
optic neuritis and is more commonly seen in Asians.

SLE or Systemic Lupus Erythematosus

In addition to neurologic involvement person has rashes over cheeks,
skin (butterfly type), arthralgia, myalgia, and renal involvement.
204 Physiotherapy in Neuro-conditions

Behcet's Syndrome
Predominant pyramidal tract involvement and psychiatric
disturbances along with eye and genital lesions.

Treatment
Medical treatment consists of glucocorticoids given with IV
methylprednisolone. Physiotherapy treatment is same as that of
paraplegias both in flaccid and spastic stage.

SPINAL ARACHNOIDITIS
Arachnoiditis of the spinal cord is a non-specific inflammatory
disease of the arachnoid membrane which is characterized
pathologically by opacification and thickening of the arachnoid
membrane with adhesion or adherence to the dura mater and
manifested clinically through roots or radicular signs and symptoms
and in severe cases even with cord compression.

Causes
1. Surgical procedures
a. Extradural causes like laminectomy, disectomy, spinal fusion.
b. Intradural causes like excision of intramedullary tumors,
rhizotomy, etc.
2. Injected agents: Spinal anesthesia, injection of contrast medium
and intradural steroids.
3. Space occupying lesions like neurofibromatosis.
4. Infections like tuberculosis and syphilis.
5. Intrathecal hemorrhage.

Pathology
Inflammatory changes in the arachnoid membrane causes hyperemia
opacification thickening and increase in the number of inflammatory
cells in the affected area because of inflammation. There is
accumulation of exudates which causes adhesions between the
fibrous tissues and also between the nerve roots and the thecal sac.
There is proliferation of fibrocytes that causes formation of collagen
fibers around the nerve roots. Because of this encapsulation of nerve
roots from all these areas hypoxia sets in leading to atrophy of the
nerve roots.