Best Physiotherapy for Tabes Dorsalis in Delhi NCR

Best Physiotherapy for Tabes Dorsalis In Delhi NCR.

What is Tabes Dorsalis ?

Tabes Dorsalis, also known as locomotor ataxia or syphilitic myelopathy, is a rare, chronic, and progressive neurological disorder that is a complication of untreated (or inadequately treated) syphilis. It is a form of late neurosyphilis, meaning the neurological symptoms manifest many years, often decades (15-30 years), after the initial syphilis infection.

Causes of Tabes Dorsalis

The sole cause of Tabes Dorsalis is infection with Treponema pallidum, the bacterium responsible for syphilis. When the syphilis infection is left untreated, or sometimes only partially treated, the bacteria can invade the central nervous system (CNS), specifically targeting the dorsal columns (posterior columns) and dorsal roots of the spinal cord.

Dorsal Columns: These pathways in the spinal cord are responsible for carrying sensory information related to fine touch, vibration, and proprioception (the sense of where your body parts are in space).
Dorsal Roots: These are the sensory nerve roots that enter the spinal cord, transmitting sensory signals from the body.

The damage to these structures is primarily due to demyelination (loss of the myelin sheath that insulates nerve fibers) and degeneration of the nerve cells and fibers. This disruption of sensory pathways leads to the characteristic symptoms of Tabes Dorsalis.

Due to widespread screening and effective antibiotic treatment for syphilis, Tabes Dorsalis has become extremely rare in developed countries. However, it can still occur, especially in individuals with untreated or undiagnosed syphilis, and there’s some concern about its re-emergence with rising syphilis rates in certain populations.

Symptoms of Tabes Dorsalis

The symptoms of Tabes Dorsalis are diverse and can be debilitating, often progressing slowly over time. They are primarily neurological due to the damage to sensory pathways.

Symptoms include:-

“Lightning Pains” : This is a classic and often early symptom. These are sudden, sharp, stabbing pains that feel like electric shocks, typically occurring in the legs, abdomen, or back. They can be severe and paroxysmal (come and go suddenly).
Sensory Ataxia: This is a major defining feature and often the most disabling symptom, leading to the alternative name “locomotor ataxia.”
- Loss of Proprioception: Inability to sense the position of one’s limbs in space without looking.
- Unsteady Gait (Tabetic Gait): A wide-based, high-stepping, uncoordinated, and often “slapping” gait. The person may lift their feet high and bring them down forcefully to compensate for the loss of proprioception, often needing to watch their feet to maintain balance. This gait is worse in the dark or with eyes closed (positive Romberg’s sign).
- Difficulty with Balance: Especially when standing or walking with eyes closed.
Loss of Deep Tendon Reflexes: Reflexes like the knee jerk (patellar reflex) and ankle jerk are diminished or completely absent due to damage to the sensory reflex arc.
Sensory Deficits:
- Loss of Vibration Sense: Inability to feel vibrations, particularly in the lower extremities.
- Loss of Position Sense: Difficulty identifying the position of a joint when it’s moved passively by an examiner.
- Diminished Touch and Pain Sensation: Reduced ability to perceive light touch, temperature, and pain, especially in the extremities. This can lead to unnoticed injuries and chronic skin ulcers.
Argyll Robertson Pupils: A highly characteristic ocular sign where the pupils constrict to accommodation (focusing on a near object) but do not constrict to light. The pupils are often small and irregular.
Bladder Dysfunction:
- Urinary Retention: Difficulty emptying the bladder completely, leading to a feeling of fullness.
- Overflow Incontinence: Involuntary leakage of urine due to a full bladder.
- Neurogenic Bladder: Impaired bladder control due to nerve damage.
Sexual Dysfunction: Erectile dysfunction in men.
Trophic Joint Changes (Charcot Joints/Neurogenic Arthropathy): Due to the loss of pain and proprioception, repetitive stress and minor injuries to joints go unnoticed, leading to progressive and severe joint destruction, most commonly affecting the knees, ankles, and hips.
Visual Disturbances: Optic atrophy leading to progressive vision loss, sometimes even blindness.
Gastric Crises: Episodes of severe abdominal pain, nausea, and vomiting that can last for hours or days.
Muscle Weakness and Wasting: Less prominent than sensory deficits, but can occur in later stages due to disuse or secondary nerve damage.

Advanced Physiotherapy for Tabes Dorsalis (including Manual Therapy)

Balance Training: Crucial to reduce falls risk and improve gait.
Strength Training: To maintain or improve muscle strength, particularly in the lower limbs.
Gait Re-education: To improve walking pattern and efficiency.

Advanced Physiotherapy :

Frenkel’s Exercises: This is a classic and highly effective set of exercises specifically designed for sensory ataxia. They are performed slowly, precisely, and with visual guidance, gradually increasing in complexity.
- Supine (lying down):
  - Heel-to-shin glides (sliding one heel up and down the opposite shin).
  - Placing heel on specific marks on the bed.
  - Alternating hip and knee flexion/extension.
- Sitting:
  - Placing foot on specific marks on the floor.
  - Knee flexion and extension.
- Standing:
  - Walking on marked lines or footprints.
  - Walking sideways, backward.
  - Turning around with controlled steps.
- Emphasis on accuracy and rhythm.
Balance Training:
- Static Balance: Progressing from sitting to standing with support (e.g., holding onto a wall/bars), then without support. Narrowing the base of support (feet together, tandem stance, single-leg stance).
- Dynamic Balance: Walking with head turns, reaching for objects, walking on uneven surfaces (initially safely within the clinic, then outdoors), obstacle courses.
- Sensory Weighting: Gradually challenging the visual system by asking patients to perform exercises with eyes closed (briefly and with close guarding) or on foam/unstable surfaces to encourage reliance on vestibular and remaining somatosensory input.
Gait Re-education:-
- Visual Cues: Using floor markers, parallel bars, mirrors to guide foot placement and body alignment.
- Auditory Cues: Using a metronome to improve walking rhythm and step length.
- Weight Shifting Exercises: To improve balance and prepare for ambulation.
- Stride Length and Cadence Training: Working on making walking more efficient and less energy-consuming.
- Treadmill Training: With or without body weight support, can be useful for repetitive gait patterning.
Strengthening Exercises:
- Focus on core stability and lower limb strength (hip abductors, quadriceps, hamstrings, calf muscles) to improve postural control and compensate for sensory deficits.
- Resistance training using bodyweight, resistance bands, or light weights.
Manual Therapy:
- Soft Tissue Mobilization: Gentle massage or myofascial release techniques to address muscle tightness or spasms that might develop secondary to altered gait patterns or disuse. This can help reduce pain and improve comfort.
- Joint Mobilizations: While direct manipulation of the affected spinal cord is not applicable, gentle, pain-free mobilizations of peripheral joints (e.g., ankle, knee, hip) can be used to maintain their range of motion and prevent secondary stiffness that might arise from limited movement or Charcot joint development. These would be very gentle, low-grade mobilizations focused on improving accessory motion rather than addressing a primary joint restriction. Crucially, manual therapy would never be aimed at “fixing” the neurological damage, but rather at managing its musculoskeletal consequences.
- Passive Stretching: To prevent contractures and maintain range of motion in joints susceptible to stiffness.

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