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Medical treatment for people with TM can be divided into three phases. The first is the acute phase which might last from days to weeks. This phase begins when a person first falls ill. Typically, that person would go to a physician for help, and the medical community would try to discover what is wrong and try to fix it. If the problem was a broken bone in the leg, this process would usually be relatively simple. X-rays would be taken, and the bone would be set or casted, if needed. In the case of transverse myelitis, a person would probably be hospitalized and have lots of tests taken, including blood tests, magnetic resonance imaging (MRI's), or computed tomography (CT or CAT) scans. A "spinal tap" might be performed to analyze the cerebrospinal fluid. Depending on the seriousness of the illness, a catheter might be inserted into the bladder to help drain urine, and a breathing tube might be inserted to help with respiration. During this time, a cause might be found and specific treatment tried, or no cause might be found. In this case, sometimes intravenous (IV) steroids may be given. Some people will recover completely. Many others will be left with lasting deficits and will need help learning how to live their lives.

After the acute phase, people with TM enter a rehabilitation phase. During this time, the focus of care shifts from trying to find a cause and treatment to learning to live with a terrible disease. Two types of accommodations must take place. First, there is coming to terms psychologically. Here a person might feel the stages of grieving as if someone had died. The loss that a person with TM feels is real. Abilities that all healthy people take for granted vanish. Even the simplest tasks become effortful. Feelings of sadness, rage, grief, remorse, and guilt are not unusual. The task confronting the person with the disease is to rebuild his or her life. Most people base their self-worth, value, and satisfaction in living, at least partially, on what they are able to accomplish every day. When a person's self-sufficiency and independence are damaged, that person must rebuild an identity that allows the person to feel proud and whole from a new set of standards. Likewise, the family and loved ones are challenged to rebuild their relationship to the injured person. This can be excruciatingly difficult, yet many people accomplish this successfully. Despite the multitude of sorrows, there are often unexpected joys, such as finding support from those who were thought unsympathetic or unavailable, and finding talents that were hidden. Although I am not disabled myself, it is my impression that this accommodation is a lifelong task. Resources that might make this adjustment easier are psychological assistance from a counselor, discussions and meetings with religious leaders and congregations, and making contact with other people who have experienced the same or similar disease or injury.

The second set of adaptations is physical. I am not aware of medical literature specifically dealing with rehabilitation after transverse myelitis. However, much has been written regarding recovery from spinal cord injury (SCI), in general, and I think that this literature applies. The physical issues include bowel and bladder management, sexuality, maintenance of skin integrity, spasticity, activities of daily living (i.e., dressing), mobility, and pain.

Of primary importance is the level at which the spinal cord has been injured. The spinal cord is typically divided into four sections: the highest is the cervical (neck) region; then in descending order are the thoracic (chest), lumbar (low back), and sacral (lowest back) regions. Nerve roots exiting the cervical cord carry messages from the brain to the arms, thoracic to the chest and abdomen (i.e., the belly), lumbar to the legs, and sacral to the leg below the knee and bowel, bladder, and sexual organs. Because the nerves must travel through the spinal cord to connect with the brain, an injury to the spinal cord at a particular level usually effects function at that level and below. Therefore, a person affected at a specific thoracic level would typically have function disrupted in trunk balance (the thoracic nerves), as well as problems with leg movement and bowel and bladder control which are supplied by the lumbar and sacral regions of the spinal cord.

The bladder is controlled by nerves exiting the low thoracic, high lumbar, and mid sacral spinal cord. Bladder function may thus be impaired in SCI. Two general problems can affect the bladder. The bladder can become overly sensitive, and empty after only a small amount of urine has collected, or relatively insensitive, causing the bladder to become over extended and overflow. An overly distended bladder increases the likelihood of urinary tract infections and, in time, may threaten the health of the kidneys. Depending on the dysfunction, treatment options include timed voiding, medicines, external catheters for males (a catheter connected to a condom), padding for women, intermittent internal catheterization, or an indwelling catheter. Surgical options may be appropriate for some people.

A common problem in spinal cord injury is difficulty with evacuation of stool, although fecal incontinence can also occur. The neurologic pathways for defecation are similar to those of the bladder. Many lacking voluntary control of the bowel may still be able to achieve continence by diet, strategic use of stool softeners and fiber, and the technique of rectal stimulation. In rectal stimulation, a finger is inserted into the rectum to cause the internal and external anal sphincters to relax allowing the stool to pass. Other aids include suppositories and oral medications. There are some surgical options, although this is rarely necessary.

Sexuality is a complex issue. The bad news may be that sexual experience is impacted by spinal cord injury. Genital function is often altered (i.e., difficulties with erection and ejaculation for men and difficulties with lubrication for women). The good news is that sensual experience and even orgasm are still possible. Lubricants and aids to erection and ejaculation (for fertility) are available. Many individuals with SCI find unexpected erogenous zones. Ultimately, sexual experience happens in the brain, not in any specific organ. Adjustment to altered sexuality is aided by an attitude of permissive experimentation, as the previous methods and habits may no longer serve.

At The Ohio State University Medical Center, a nursing clinic is dedicated to provide practical help in matters of bowel, bladder, and sexuality for people with disabilities.

Skin breakdown occurs if the skin is exposed to undo pressure for a sufficient amount of time. Skin integrity is maintained in people without disabilities by two related mechanisms. First, the able-bodied have sensation, so that if they sit in one position for too long, they get uncomfortable. Secondly, they have the strength to shift position as necessary. Either or both of these mechanisms can be impaired in SCI. Sitting position should be changed at least every 15 minutes. This can be accomplished by standing, by lifting the body up while pushing down on armrests, or by just leaning and weight shifting. Wheelchairs can be supplied with either power mechanisms of recline or tilt-in-space to redistribute weight bearing. A variety of wheelchair cushions are available to minimize sitting pressure. Redness that does not blanch when finger pressure is applied may signal the beginning of a pressure ulcer. Good nutrition, vitamin C, and avoidance of moisture all contribute to healthy skin. Pressure ulcers are much more easy to prevent than to heal.

When the spinal cord is injured, muscle groups below the level of injury may become spastic. This manifests as stiffness and resistance to movement. They may also become hyper-reflexic and jerk when touched or hit. The cause of this is not fully understood. The management of spasticity must always be based on the person's function. For example, some people with TM will use the spasticity in their legs to help them walk. If this is treated, they may lose this ability. In contrast, someone whose spasticity prevents them from sitting in a wheelchair must be treated. If there has been a recent increase in spasticity, it is important to search for a cause. Noxious stimuli such as ingrown toenails, urinary tract infections, bowel impaction, kidney or gallbladder stones must be suspected.

Medical treatment of spasticity centers around four medications. Baclofen (Lioresal) is thought to inhibit reflex activity. It is considered the drug of choice for spasticity due to spinal cord injury. It is generally well-tolerated although it can be sedating. Abrupt discontinuation of baclofen can cause seizures and hallucinations. Diazepam (Valium) works by a similar mechanism, but is more likely to be sedative, and has been implicated in slowing recovery from brain injury. Dantrolene sodium (Dantrium) affects the muscles directly. While it is considered to be the drug of choice to treat spasticity due to brain injury, it may also play a role as an adjunct in the treatment of SCI spasticity. Tizanidine (Zanaflex) is a new drug to the US, but has been available in Europe for a long period of time. It reduces spasticity by a different mechanism than baclofen or dantrium and is generally well tolerated. Because it is more expensive than baclofen, and because most US physicians have less experience with it, it usually would not be the first choice.

Individuals with TM may find ordinary tasks such as dressing, bathing, grooming, and eating very difficult. Many of these obstacles can be mastered with training and specialized equipment. For example, long handled sponges can make bathing easier as can grab bars, portable bath seats and hand-held shower heads. For dressing, elastic shoe laces can eliminate the need to tie shoes while other devices can aid in donning socks. Occupational therapists are specialists in assessing equipment needs and helping people with limited function perform activities of daily living. A home assessment by an experienced professional is often helpful.

Physical therapists assist with mobility. Besides teaching people to walk and transfer more easily, they can recommend mobility aids. This includes everything from canes (single point vs. small quad cane vs. large quad cane) to walkers (static vs. rolling vs. rollator) and braces. For a custom-fabricated orthotic (brace), an orthotist is necessary. Careful thought should go into deciding whether the brace should be an ankle-foot orthosis, whether it should be flexible or stiff, and what angle the foot portion should be in relationship to the calf portion. Some will benefit by a knee-ankle foot orthosis.

Each person should be evaluated individually. I believe that the best results occur when the team is coordinated by a physician so that the therapists and orthotists are united with the patient on what is to be achieved. The physician best trained to take this role is the physiatrist.

Pain is common following SCI. The first step in treating pain effectively is obtaining an accurate diagnosis. Unfortunately, this can be very difficult. Causes of pain include muscle strain from using the body in an unaccustomed manner, nerve compression (i.e., compression of the ulnar nerve at the elbow due to excessive pressure from resting the elbow on an armrest continuously) or dysfunction of the spinal cord from TM. Muscle pain might be treated with analgesics, such as acetaminophen (Tylenol), non-steroidal, anti-inflammatory drugs such as naproxen or ibuprofen (Naprosyn, Aleve, Motrin), or modalities such as heat or cold. Nerve compression might be treated with repositioning and padding (i.e., an elbow pad for an ulnar nerve compression).

Nerve pain from the spinal cord is sometimes called "dysasthetic pain". Because of the SCI due to TM, nerve messages traveling through the spinal cord may become scrambled and misinterpreted by the brain as pain. Besides the treatments listed above, certain antidepressants such as amitriptyline (Elavil), or anticonvulsants, such as carbamazepine, phenytoin, or gabapentin (Tegretol, Dilantin, Neurontin) may be helpful. Stress and depression should also be addressed since these conditions make pain harder to tolerate.

This brief overview is not meant to include all possible areas of concern. I am grateful for the editing provided by Cindy Gatens.