Case Report : Physiotherapy management of maternal obstetric palsy in a Nigerian teaching hospital

Patient characteristics and history

Patient F is a 38-year-old multigravida and multiparous (four pregnancies, three life births, one still birth) who was admitted in the obstetrics and gynaecological ward of the University of Port Harcourt Teaching Hospital on 6^th April 2020 following a prolonged obstructed labour (>18 hours), and uterine rupture in a private hospital (name unknown). The outcome of the delivery was a male fresh still birth weighing 4.2 kg. The mother’s height was 5′2′′ (157.5 cm). The patient developed difficulty in moving her lower limbs after the delivery. She also underwent explorative laparotomy and repair of the uterine rupture.

The patient had no known previous medical or surgical history and had delivered her previous three pregnancies (two males and one female) through spontaneous vaginal delivery.

Clinical examination and findings

The physiotherapy team was invited on 7^th April 2020 by the attending consultant obstetrician and gynaecologist. The patient complained of severe pain (10/10 in the verbal rating scale) and bilateral weakness of both lower limbs. On palpation, she had tenderness in both lower limbs. Her muscle tone was normal bilaterally. She also complained of intermittent muscle spasm of moderate intensity. There was loss of sensation to deep and light touch, and cold and heat below the L3 dermatome. No autonomic affectations were observed, as patient had good urine and faecal control.

Active ranges of motion in all joints of the lower limbs were limited due to muscle weakness. Muscle testing was carried out manually and graded using the Oxford Muscle Grading system (Table 1). Passive ranges of motion in all joints of the lower limbs were full and painful. Functionally, the patient could perform activities of daily living involving the upper limbs but could not turn on the bed, sit or stand without support, and could not walk.

Diagnosis

There was absence of electromyography in the facility; hence, nerve conduction test was not performed. A multidisciplinary team meeting involving the gynaecologists, women’s health physiotherapists and nurses was held, and after repeated consultations and deliberations, a final diagnosis of maternal obstetric palsy was made. The decision was based on the patient’s history and clinical presentations (patient’s signs and symptoms became evident after childbirth) which were strongly indicative of maternal obstetric palsy.

Interventions

The treatment goals planned in agreement with the patient and caregivers were to relieve pain, decrease muscle spasm, improve/restore sensation, improve muscle strength, prevent further deterioration, and retrain lower limb function. These were achieved using cryotherapy, transcutaneous electrical nerve stimulation, isometric muscle exercise, active and resisted exercises, proper positioning of the lower limbs with the hips in extension and slight abduction, and knees in extension, and splinting of the ankle joints in dorsiflexion, and gait re-education. The use of cryotherapy to reduce muscle spasm was changed after the first week of treatment when the team observed that despite the immediate reduction in spasm following cryotherapy, the relief of symptoms was transient, and the patient experienced severe pain subsequently.

The Transcutaneous Electrical Nerve Stimulation was set on the normal (N) mode with a frequency of 100 Hz, pulse width of 150 μs for a duration of 40 minutes. The intensity of the stimulation was set according to the patient’s tolerance level starting with 2 mA and concluding with the intensity the patient could tolerate, which was 6 mA.

The isometric muscle exercise was targeted at the hip adductors and quadriceps bilaterally. The exercise involved the patient squeezing an improvised safe water bottle between both thighs for the adductors and under the thighs for the quadriceps, for 5 seconds during each repetition. This was performed for 5 sets with rest between repetitions. The exercise was progressed after the first four weeks by increasing the time to 10 seconds during each repetition. The number of sets was not increased.

The active exercise was targeted at each muscle group of the lower limbs. The exercise pattern followed a cephalocaudal direction starting from the muscle groups of the hip joints and ended with the muscle groups of the ankles, and alternately starting from the right limb to the left limb for each muscle group. The patient was asked to perform these movements, in five repetitions for each muscle group, and two sets between rests. The volume of the exercise was increased every two weeks by increasing the number of repetitions for each muscle groups by five and the number of sets by two.

The resisted exercise was also targeted at each muscle group of the lower limbs. Resistance was provided manually by the physiotherapist on duty and was commenced after one month of admission, when the muscle strength had improved to 3/5 of OMG. The resisted exercise pattern followed the same pattern of direction and progression as the active exercise.

The patient’s feet were put on splints (using a crepe bandage) in a dorsiflexed position to correct the foot-drop deformity. The patient was advised to put on the splints when lying in bed during the day (at least for five hours) and throughout the night and remove them during exercise and other activities outside the bed.

Ward programmes emphasised isometric and active exercises, natural positioning of the limbs with the hips in extension and slight abduction, and knees in extension, and adherence to the use of the splints for both feet, positioning the feet in dorsiflexion. The patient was taught how to carry out the exercises correctly in line with the prescription.

Patient was seen twice a day on workdays; during the morning ward rounds and during the evening call duty. During the weekends (Saturdays and Sundays), the patient was seen once a day during call duty.

Adverse and unanticipated events

The patient underwent emergency explorative laparotomy with total abdominal hysterectomy for necrotic uterus and repair of necrotic bladder. She was admitted in the intensive care unit (ICU) afterwards and was discharged from the ICU after two days. The patient had a subsequent wound breakdown due to bacterial infection after one week. Hence, she was referred for surgical repair of burst abdomen. She was also placed on antibiotics for infection and high protein diet to encourage wound healing. These events especially the wound breakdown affected the patient’s prognosis and delayed her discharge.

In view of the above events, the physiotherapy exercises were tailored to be more pragmatic with clinical precautions taken to ensure that exercises did not excessively increase intra-abdominal pressure. During exercises, external support was provided using a wrapper that was firmly applied to the abdomen to counter any slight increase in intra-abdominal pressure.

Follow-up and outcomes

After six weeks of physiotherapy, the patient still complained of mild pain and mild intermittent spasm bilaterally on the lower limbs, and inability to walk well. On assessment, she rated her pain as 2/10 on the verbal pain rating scale. Active and passive ranges of motion were full and pain-free on all joints except on the left ankle which is limited and painful. The patient’s sensation to both light and deep touch had been restored. Muscle strength was retested manually and graded through the Oxford Muscle Grading as shown in Table 1. Functionally, the patient could move in and out of bed, could stand without support and could walk a short distance without support. She could perform all her ADLs. However, she walked with abnormal gait (limping, no heel strike on the left lower limb and hyperextension of the left knee). In view of the above improvements, the team decided to continue with current line of management, and gait retraining was commenced.

Gait retraining involved standing re-education which progressed to stepping re-education, and finally to short and long-distance walking. These involved the use of a Zimmer Frame, with support from the physiotherapist.

After additional two weeks of physiotherapy, the patient complained of no pain and no spasm on the lower limbs. Patient could walk a long distance. Muscle strength was retested manually and graded through the Oxford Muscle Grading as shown in Table 1. Functionally, the patient could perform all her ADLs. However, she was still walking with a high steppage gait on the left foot.

The patient was discharged following the secondary wound closure. Before discharge, she underwent a pre-discharge physiotherapy training where she was taught the correct strengthening exercises for the ankle dorsiflexors. The exercise prescription for the dorsiflexors comprised free active exercise of 10 repetitions and five sets twice every day and resisted exercise of five repetition and five sets twice every day. A dynamic ankle-foot splint was also prescribed. The patient was encouraged to perform these exercises in the correct manner following the prescription, and to also wear the splint as soon it was purchased for as long as she could.

A member of the physiotherapy team was constantly in contact with the patient and caregiver after discharge through phone call and WhatsApp. This was to ensure she was adhering to the exercise prescription and had purchased the splint and wearing it as prescribed. Occasionally, the patient was requested to make a video of her exercise session and how she was wearing the splint. Necessary corrections, advice and encouragement were given. The caregiver was also requested to make a video of the patient walking (when she was not aware) to assess improvement in her walking pattern. Her gait pattern was observed to have progressively improved. The physiotherapy team lost contact with the patient and caregivers after three months.