Why a Person with TM Should Consider Physical Therapy
Originally Published in The Transverse Myelitis Association Newsletter
Volume 3 Issue 2
Robin Sopher is a Physical Therapist at The Ohio State University Outpatient Rehabilitation Department. She received her BS degree in Physical Therapy from The Ohio State University College of Allied Medicine. She has participated in prosthetic and orthotic clinics at both the Medical College of Ohio and The Ohio State University. She has special interests in orthopedic structural assessments and bracing/orthotics. She works with clients diagnosed with either orthopedic and/or neurological problems.
One may ask; what is a physical therapist and what could a physical therapist do for me? A physical therapist is a specialist trained to evaluate and treat neuromuscular and musculoskeletal disorders. Physical therapy means the evaluation and treatment of a person by physical measures and the use of therapeutic exercises and rehabilitative procedures for the purpose of preventing, correcting, or alleviating disability. As physical therapists, our goals are to strive to train and teach each client to be as independent as possible. We may use modalities (various machines) to relieve or minimize pain and to try to optimize strength gains. We make our patients work hard, not because we like to see people sweat, but rather the fact that we want the clients to maximize the quality of their lives. To become a physical therapist, one must complete two years of undergraduate work, apply to a physical therapy program and then undergo two to three years in a physical therapy program. This will give a therapist a BS or MS degree depending on the length of the program. Some therapists may go on to achieve one or more specialist degrees. We are then required to attend a specific number of continuing education courses every two years.
When a therapist initially sees a client, he/she performs an initial evaluation. This consists of a thorough exam of medical history, current medications, pain, client goals, muscle strength, range of motion of the joints, gait (walking), posture and structural assessment, balance, sensation, specialized tests, functional abilities and basic neurological testing. This tells us the client’s baseline so that we can assess progress during the duration of treatment. We continue to reevaluate the above information to advance the difficulty of their program.
Physical therapists work with clients that have been diagnosed with transverse myelitis (TM) in various settings. One may initially see a physical therapist (PT) in acute care (hospital), inpatient rehab (when the client is still staying in a rehab center), outpatient rehab (when the client has been discharged to home) or home health rehab (if the client is considered home bound).
When one reads about the rehabilitation for a client with TM, it may be compared to the rehabilitation of a client with a spinal cord injury. This is because the resulting physical effects are similar. A spinal cord injury (SCI) can be categorized into a complete or incomplete SCI. A complete means the patient does not have sensation or motor function including sacral segments of the spine. We may see this with severe cases of TM or in the beginning stage of TM. Usually within 1-3 months, you may begin to see these strength and sensation deficits change in an individual with TM, but this does not change in an individual with a complete SCI. However, an individual with an incomplete SCI may have similar changes. The difference between SCI and TM is the method of injury to the spinal cord. A SCI is usually the result of a traumatic incident like a car accident, fall, gunshot wound, etc. and TM is caused by inflammation of the spinal cord.
An individual with an incomplete SCI and an individual with TM present with similar abilities.
Both of these diagnoses, however, have various types of clinical presentations. This means the return of strength and sensation in various combinations in the body. There are no two people that present with all the same symptoms. It depends on what areas and what levels of the spinal cord are injured. The physical therapist’s general plan is the same for both of these clients, to continue to strengthen and maximize function of whatever the client has remaining. Individualized goals will be set from that initial evaluation. Some individuals will return to walking, some may not. Let’s say a person gets strength back in most of the muscles on one side of the body, but the foot on that side is weak and limits their ability to pick up their foot without falling. We may choose to use a brace at that point to assist those muscles in which the strength does not return, which allows the person to still walk safely. Again, the goals of physical therapy are to make the client as independent as possible.
Because a physical therapist is highly trained in gait evaluation, he/she is able to determine if a type of bracing for the lower extremities would be appropriate. He/she can fabricate a temporary brace to help during gait training, but an orthotist fabricates a more permanent brace. All the decisions about bracing must be approved by one’s physician. A therapist usually tries to delay recommending a permanent brace for the feet or legs until the end of therapy. The reason this is done is because the client’s strength may change. When selecting a brace, one must feel fairly confident that the current strength of the area being braced has reached a plateau or will not be making any immediate dramatic changes. For example, if a client started out with significant weakness upon the initial evaluation, one may recommend long leg braces (braces extending up to the thigh area) at that time. However, during therapy this client’s strength may change to the point where at the end of therapy he may only need an AFO (a brace extending to just below the knee). Therefore, the effectiveness of the brace depends on an overall evaluation of the client’s abilities and an observation of his/her progress over time.
The treatment plan is different for each client. The treatment plan refers to what the client will be doing each time he/she comes for a session and the overall strategy to reach the patient’s individual goals. The plan is developed based on the initial evaluation of the client’s abilities. Strength is a major factor in determining what types of treatments are appropriate. Strength is classified on a scale of 0-5. Zero meaning that there is no palpable or visual contraction of a muscle and five meaning that the therapist cannot break the client’s contraction of the muscle. In between, one through four, are various intensities of muscle contractions. The treatments may initially start with teaching strategies for basic self-care and daily living needs. For example, learning to roll over in bed, sit up, transfer from the bed to a chair, sit to stand, transfer for bathing and toileting, etc. An initial exercise program should be initiated for whatever level of strength the individual has. Aquatic therapy is very beneficial in the beginning, because the buoyancy of the water can be used in ways to assist the client’s movements. Buoyancy is a property of water that exerts an upward force. This will make the limb feel lighter. There will be exercises the client can do in the water that he/she cannot do on land. Walking can also be facilitated earlier in the water as opposed to land therapy. The physical therapist will ensure that there are components of both land and water therapy to ensure optimal carryover regarding function. One should be prepared for changing levels of assistance needed by others. In the beginning, a lot of assistance from your therapist may be needed to move and this should gradually decrease during your therapy, depending on your potential for recovery.
Land therapy or therapy in the gym/community will progress as one’s strength progresses.
Physical therapists are known to always make exercises harder when they become easy! This challenge to the muscles is necessary for strength gains. Some exercises may not seem like what one is used to, therefore the therapist will usually explain their rationale for his/her creative exercises. These creative exercises are not only to add some fun to therapy, but most importantly to add balance training, multiple simultaneous muscle function, coordination training, etc. The client may do work with swiss balls, balance machines, cones, therabands, traditional weights, parallel bars, rocker boards, etc. Electric stimulation machines may be used to help facilitate stronger muscle contractions during the exercises. During gait training, one may progress through the use of various assistive devices. They may start with a walker (one with wheels or no wheels) and progress to a quad cane (four-prong cane) or straight cane. Some clients may benefit more from loftstrand crutches (forearm crutches). The amount of bracing needed for the legs will also help to determine what type of assistive device will be achievable.
Part of inpatient and outpatient rehabilitation is to help orient the client back into the community with the new strategies they have learned. Tasks that were not given any consideration prior to the injury, at first, seem like overwhelming obstacles. Activities such as grocery shopping, going to a restaurant, or going to a mall may be community activities in rehab. This lets the physical therapist evaluate the client’s ability to walk or propel their wheelchair community distances, cross the street in a safe amount of time, negotiate curbs/ sidewalks/ stairs/ inclines, open doors, negotiate shopping carts, public restroom accessibility, elevators, escalators and any other community obstacle available. This lets the client try these tasks with the safety of their therapist if they may need help or direction. The chance to do this is a large step toward gaining a sense of independence.
Another area in which a therapist can be of assistance is to decrease or alleviate pain. Pain may manifest itself in various forms in a client with TM. It could be joint or muscle pain in which stretching may help. It could be due to faulty posture in a wheelchair or while sleeping and the therapist can recommend changes. If it is due to nerve pain, a tens unit may help. Sometimes a previous problem can be exacerbated by the current muscle weakness and types of support may be recommended. Physical therapists also use machines to heat tissues to facilitate stretching and help with inflammation and the pool can even be used to decrease pain secondary to the warmth of a therapeutic pool.
I, myself, have seen individuals with various severities of TM. I have seen clients that needed assistance for self and home tasks at the end of therapy. I have seen individuals that regained enough strength to function independently, but needed the use of bracing and/or a wheelchair. I have also seen individuals that were able to return to walking and independent living. Each stage is difficult for the client, because they are never sure exactly what they will get back and they are forced to find new ways to do previous tasks. If someone will need to use a wheelchair, even part of the time, a team of experts should recommend it. The posture one has in a wheelchair can influence their skin, breathing, eating, comfort, proper joint function, proper muscle function and level of community function.
What would happen to someone with TM if they did not receive physical therapy? They would not maximize their potential for recovery of function. It could be compared to an athlete without a coach. A therapist is trained to evaluate and recommend appropriate treatment during the entire duration of recovery. Something as minor as an ankle becoming tight while you are in a stage of relative inactivity can become major if it is allowed to stay tight for too long. It can significantly impact your ability to walk. Problems such as this are caught early by a physical therapist and actions are taken to avoid or correct them.