IVIAART" 1977 F I S I O T E R A P I E 5 The role of Physiotherapy in the management of Tuberculous Meningitis in children C. A . L IG G IN S , M .C .S.P ., H .T ., D ip .T .P . /$ e n io r L e c tu re r in P h y s io th e ra p y , J o i n t M e d ic a l E s ta b ­ lishment, N a ta l P ro v in c ia l A d m in is tra tio n /U n iv e rs ity o f D u rb a n -W e s tv ille ) T u b e r c u l o u s m e n i n g i t i s is t u b e r c u l o u s in fe c tio n o f th e m e n in g es lo c a lis e d m a i n l y to t h e b a se o f th e b ra in . It is th e w o rst c o m p lic a tio n o f tu b e rc u lo s is a n d a c o m ­ mon cause o f d e a th fro m th e tu b e rc le b a c illu s in chil- dren.(1) I f it is n o t tre a te d it is a lw ay s f a ta l o r if treatm ent sta rts la te in th e dise ase a n d th e p a tie n t does «urvive, th e re m a y be m e n ta l r e ta r d a tio n a n d /o r p a ra ly sis %f som e d e g ree . T u b e rc u lo u s m e n in g itis affects c h ild re n m u c h m o re than a d u lts a n d th e y o u n g e r ch ild is u su a lly m o re se ri­ ously affected th a n th e o ld e r o n e ; th e g re a te s t m o rta lity appears in th e age g ro u p f o u r y ears a n d below . Statistics in re sp e c t o f th e in c id e n c e a n d m o rta lity rates of tu b e rc u lo u s m en in g itis h a v e p ro v e d difficult to obtain fo r m o st c o u n trie s in th e A fric a n c o n tin e n t a n d other d e v elo p in g c o u n tire s. P erusal o f W o rld H e a lth O rg a n is a tio n figures b etw een 1970 a n d 1972 sh o w th a t th e m o r ta lity ra te p e r 100 000 p o p u latio n v a rie d b e tw ee n 11,3 in A rg e n tin a d u rin g 1970, and 0 in Isra e l d u rin g 1972. T h e s e figures a re f o r c h ild ren of 14 y e a rs a n d b elow . F igures o b ta in e d fro m th e 1974 A n n u a l R e p o r t o f th e State H e a lth D e p a r tm e n t o f th e R e p u b lic o f S o u th Africa sh o w th a t 409 cases o f tu b e rc u lo u s m e n in g itis w ere notified in a to ta l n u m b e r o f T .B . cases o f a ll fo rm s of 57 820.<2> T h is figure, th o u g h re la tiv e ly sm a ll, does, however, in d ic a te t h a t tu b e rc u lo u s m en in g itis is a c o m ­ mon c o m p lic a tio n o f T .B . a n d in 1974 it sto o d jo in t seventh in th e le a g u e o f 31 n o tifia b le diseases, It has b een sta te d t h a t w ith m o d e rn tr e a tm e n t th e re is 1 0 0 % re c o v e ry w ith o u t se q u e la e if tre a tm e n t f o r t u b e r ­ culous m en in g itis is b e g u n b e f o re th e c h ild b e co m es u n c o n sc io u s /3) T h e m o st im p o r ta n t fa c to r w hich d e te r ­ m in e s th e u ltim a te p ro g n o sis is th e tim e w h ic h elapses " e tw e e n th e o n se t o f th e sy m p to m s a n d th e b e g in n in g o f the specific tre a tm e n t. In the D u rb a n u n it, a t K in g G e o rg e V H o s p ita l, it is considered th a t if cases a re a d m itte d a n d s ta rt tre a tm e n t within 1 0 d ays o f o n s e t o f sy m p to m s, th e re s h o u ld be com plete re co v e ry . H o w e v e r, o n th e a v e ra g e , th e cases are a d m itte d a t th e 2-3 w eeks stage, a n d th is h a s re su lte d in a re co v e ry r a te o f 73% o f w hich 50% a re m e n ta lly or physically h a n d ic a p p e d o r b o th . In 1974, 77 c ases w e re a d m itte d to th is u n it a n d judging by these a d m iss io n s th e incid e n ce o f tu b e rc u lo u s m eningitis d oes n o t seem to be declin in g ; in fa c t it does tend to serve as an in d e x to th e in c id e n c e o f T .B . as a whole. PATHOLO GY W ith tu b e rc u lo u s m en in g itis, p rim a ry tu b e rc u lo s is is always p re se n t in itia lly in so m e o th e r p a r t o f th e body. T h ere a re tw o m o d e s o f sp re a d to a ffect th e m en in g e s, one in w hich th e re is a la te n t p e rio d b e fo re th e m e n in ­ gitis m an ifests itself, e x ce p t in v e ry y o u n g c h ild re n w h e re the sp re ad c o in c id es w ith th e p ro g re s sio n o f th e p rim a ry lesion, a n d a se c o n d , re su ltin g fro m m ilia ry tu b e rc u lo s is, which h as a m u c h q u ic k e r o n se t. T h is p a p e r w a s p re se n te d a t the R e g io n a l C o n g re ss o f the C o m m o n w e a lth M e d ic a l A s s o c ia tio n (L e so th o 1975). 1. W h e n p rim a r y tu b e rc u lo sis d e v e lo p s in th e lung, a “ p rim a ry fo c u s” is fo rm e d . F r o m th is th e re is d r a in ­ age to th e lo c a l ly m p h g lan d s. T h e p rim a ry fo c u s a n d th e a ffected g la n d s a re k n o w n as th e “p rim a ry c o m p le x ” . A few tu b e rc le b a c illi b re a k a w ay fro m this p rim a ry c o m p le x to cause a b a c te ra e m ia . M o s t o f th e s e a re c o m b a te d by th e b o d y ’s d e fen c es b u t so m e e v e n tu a lly lo d g e in v a rio u s p a rts o f th e b o d y a n d re m a in in ac tiv e . T h e n , d u rin g p e rio d s o f stress, m a ln u tritio n , o th e r in fec tio n s o r tra u m a , th e tu b e rc le b a cilli m ay be co m e a ctiv e a n d grow . C o m m o n sites fo r th is to o c c u r a re th e b r a in , b o n e s, jo in ts a n d k id n ey s. In th e b ra in a “ R ic h ’s fo c u s” is fo rm e d ; if th is b re a k s d o w n it d isc h a rg e s in to t h e su b -a ra c h n o id sp a c e to c au se tu b e rc u lo u s m en in g itis. 2. In m ilia ry tu b e rc u lo s is th e r e isi a r u p t u r e o f th e tu b e rc u lo u s p ro c e ss w hich d isc h a rg e s d ire c tly in to th e b lo o d stre a m to c au se a tu b e rc u lo u s se p tic ae m ia . W h e re v e r th e tu b e rc le b a cilli th e n settle, tro u b le w ill be cau sed . In su c h cases, a u to p s y has sh o w n t h a t tu b e rc le b a c illi a re fo u n d in a lm o s t e v e ry o rg a n o f th e b ody. T u b e rc u lo u s m e n in g itis is a lw a y s a m en in g o -en c e - p h a litis a n d th e g re a te s t in v o lv e m e n t is fo u n d in th e re g io n a r o u n d th e C irc le o f W illis. T h e e x u d a te w hich fo rm s a t th e b a se o f th e b r a in in volves c ra n ia l n e rv e s a n d m ay c au se o b s tru c tio n o f th e b a sa l ciste rn s, w h ich in tu r n w ill give rise to h y d r o ­ c e p h a lu s , w h ich is m a d e w o rse by excess se c re tio n o f c e re b ro -s p in a l fluid a n d p o o r re -a b s o rp tio n . V a s c u la r c h an g e s fre q u e n tly o c c u r in tu b e rc u lo u s m en in g itis, th e b lo o d vessels b e c o m in g o c c lu d e d as a re s u lt o f tu b e rc u lo u s e n d a rte ritis , a n d c e re b ra l in fa rc tio n o f g re a te r o r lesse r d e g re e follow s. S IG N S A N D S Y M P T O M S It w as s ta te d e a rlie r t h a t th e tim e lap se b e tw e e n th e o n se t o f sy m p to m s a n d th e b e g in n in g o f specific t r e a t ­ m e n t is th e m o s t im p o r ta n t fa c to r in d e te rm in in g th e p ro g n o sis. I t is th e r e f o r e m o st im p o r ta n t t h a t a ll m e m ­ bers o f th e h e a lth tea m , as well as d o c to rs , a re a b le to re c o g n ise th e signs a n d sy m p to m s o f th is c o n d itio n . T h e m o th e r is u s u a lly a re lia b le w itn ess; sh e k n o w s th a t th e re is s o m e th in g w ro n g w ith h e r c h ild . U n f o r tu n ­ a te ly th e e a rly m a n ife s ta tio n s o f tu b e rc u lo u s m en in g itis, i.e. p y re x ia a n d v o m itin g , a re c o m m o n to se v e ra l o th e r, less severe, c h ild h o o d d iseases. T h e m o th e r will seek h e lp fro m a d o c to r, b u t w hen th e c h ild does n o t re sp o n d , she w ill p ro b a b ly ta k e th e c h ild to o n e o r e ven tw o m o re d o c to rs ; th u s it b ecom es difficult f o r a n in d iv id u a l ju d g m e n t o f th e c o u rse o f tu b e rc u lo u s m e n in g itis to be m a d e a n d th e o p p o rtu n ity to m a k e a n e a rly diag n o sis m a y be lo st in th is way. T h e signs a n d sy m p to m s o f tu b e rc u lo u s m en in g itis m a y b e c o n v e n ie n tly d iv id e d in to th r e e stages. Stage 1 — (th is m ay la s t u p to 7-10 d ays). T h e o n se t is in sid io u s w ith g e n e ra l signs a n d sy m p to m s R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 P H Y S I O T H E R A P Y M ARCH , 1977 su c h as' p y re x ia , v o m itin g w h ic h is n o t re la te d to the in ta k e o f fo o d , d ia rrh o e a in so m e cases, so m e tim es a full fo n te n e lle a n d th e n n e ck stiffness. Stage 2 — (th is sta g e so m e tim es s ta rts a b ru p tly ). T h e re is a c o n tin u a tio n o f th e g e n e ra l sy m p to m s w ith th e o n se t o f n e u ro lo g ic a l sy m p to m s, e.g. a p a th y , d ro w si­ ness, su d d e n c ry in g o r sc rea m in g , w e ak n e ss o f a lim b o r lim bs, tre m o r, g e n e ra lise d restle ssn ess, a s q u in t o f su d d e n o n se t, o th e r c ra n ia l n e rv e pa lsie s, neck, stiffness a n d a b u lg in g fo n ta n e lle in in fa n ts. Stage 3. T h e n e u ro lo g ic a l signs a n d sy m p to m s b e co m e m ore se v e re w ith c o n v u ls io n s , in a b ility to sw allo w , o r ta lk a nd u n c o n sc io u sn ess. C o n v u lsio n s c a n o c c u r in a n y stage o f th e dise ase, a nd fro m the p o in t o f v iew o f e a rly d iag n o sis a n d tre a tm e n t a n d th e re fo re p ro g n o s is th e e a rlie r th e y o c c u r th e b e tte r. C o m p la in ts m a d e by c h ild re n o ld e n o u g h to ta lk a re v e ry v a rie d , th e m ain o n e s b e ing: (i) v o m itin g — w hich c o m e o n su d d e n ly , (ii) a b d o m in a l p a in , (iii) p e rsiste n t h e a d a c h e , (iv) p a in in th e legs w hich a re o f te n d ra w n up. T h e n e u ro lo g ic a l in v o lv e m e n t o f th e se c o n d and th ird stages -may b e d u e to o n e o r c o m b in a tio n s o f th e fo llo w ­ ing fa c to rs: (a) th e tu b e rc u lo u s e x u d a te p re v e n tin g a d e q u a te c irc u la ­ tio n o f th e c e re b ro -sp in a l fluid in th e b ra in , the re s u lta n t rise in in tra c ra n ia l p re s s u re c au sin g th e b ra in s u b s ta n c e to be c o m p re ssed a g a in st th e skull; (b ) th e in fla m m a to ry p ro c e ss w h ic h a u g m e n ts th e p re s ­ su re m e n tio n e d above; (c) th e tu b e rc u lo u s e n d a rte ritis c au sin g in fa rc tio n w hich m ay give rise to n e cro sis o f b ra in tissue. D iagnosis: D ia g n o sis is u su a lly m ade w hen th e re su lts o f th e tu b e rc u lin test, c h e s t X -ra y a n d e x a m in a tio n o f th e - c e r e b r o - s p in a l fluid b e c o m e a v a ila b le . H o w e v e r, in view o f th e se rio u s c o n se q u e n c e s o f d e la y ed tre a tm e n t it is im p e ra tiv e t h a t th e a p p r o p ria te tre a tm e n t f o r the su sp ec ted tu b e rc u lo u s m en in g itis b e in stitu te d w h ilst th e n e c e ssa ry in v e s tig a tio n s a re b e ing c a rrie d o u t. Treatm ent: T h e su c c essfu l o u tc o m e o f t h e . tre a tm e n t o f th is dise ase is d e p e n d e n t on e a rly d iag n o sis a n d v ig o ro u s tre a tm e n t. T h e g u iding p rin c ip le s o f tre a tm e n t a re: 1. T h e u se o f a n ti-in fia m m a to ry a g e n ts in a ll cases. 2. T h e use o f a n ti-tu b e rc u lo u s d ru g s w h ic h e n te r th e th e c a freely. 3. T h e c o n tro l o f ra is e d in tra -c ra n ia l p re ssu re . 4. N u rs in g c a re a n d th e c o n tro l o f c o n v u lsio n s. 1. Anti-Inflam m atory A gents. T h e s e s h o u ld b e given as a r o u tin e to a ll p a tie n ts on ad m issio n . A .C .T .H . gel, C o rtiz o n e a n d B u ta z o lid in m ay be given sin g ly o r in c o m b in a tio n , th e la tte r m o s t c o m m o n ly o n ly in su sp ec ted in fa rc tio n o f th e b ra in . 2. A n ti-T u berculous D rugs. T h e r e a re a n u m b e r o f d ru g s a v a ila b le . A n im p o r ta n t p o in t w h ic h m u s t b e c o n sid e re d w h e n se lec tin g th e d ru g is t h a t it s h o u ld b e o n e t h a t e n te rs th e c e re b ro ­ sp in a l fluid re a d ily a n d in th e re a p e u tic a m o u n ts. S om e d rugs u se d in th e K in g G e o rg e V H o s p ita l are: (i) l .N . A . H . ( N e o te b e n ). T h is is e ffective e v en when given a lo n e a n d m u st a lw ay s b e given even if other d ru g s a re used. I t m u st be in tro d u c e d by in tra ­ m u sc u la r in je c tio n , as in tro d u c tio s b y th e o ra l route is u n re lia b le due to v o m itin g o r m a l-a b s o rp tio n . Jt is u su a lly re q u ire d fo r 2-3 m o n th s b y in je c tio n and th en c o n tin u e d by m o u th . (ii) E th io n a m id e . T h is is w ell to le ra te d b y c h ild ren . I t is given ro u tin e ly b e c a u se o f th e fe a r o f in fe c tio n o f a ch ild b y l.N .A .H . re s is ta n t organism s. (iii) E th a m b u to l is also used ro u tin e ly . (iv) R ifa m p ic in is u n d e r tria l. N .B . S tre p to m y c in is seldom re q u ire d now , b u t it is only effective if given in tra th e c a lly as well as b y in tra ­ m u s c u la r in je c tio n , as in su fficien t e n te rs th e theca if given b y in tra m u s c u la r in je c tio n only. 3. Control o f Intra-cranial Pressure. T h is m ay be life-saving in th e first few d ays a nd m ay be d o n e by re p e a te d lu m b a r p u n c tu re s , o r if sp in a l b lo ck is p re se n t, by v e n tric u la r p u n c tu re . ^ 4. Nursing. In th e K in g G e o rg e V u n it th e n u rs in g o f the p a tie n t is re g a rd e d as th e m o st im p o r ta n t p a r t of th e tre a tm e n t, fo r it is o fte n o n ly c a re fu l nursing th a t k e e p s th e p a tie n t a live lo n g e n o u g h f o r the d ru g s to b e effective. N u rs in g s h o u ld be a lo n g th e lines o f g o o d g eneral care; how ev er, th e fo llo w in g p o in ts a re specific to th e n u rsin g o f tu b e rc u lo u s m eningitis: (a) P re s s u re sores sh o u ld be p re v e n te d by the use o f fo a m ru b b e r u n d e r th e p re ssu re p oints, esp e cially th e head. (b) I f th e ch ild is u n a b le to sw allo w , tu b e feeding w ill b e necessary. T h e tu b e sh o u ld b e re m o v e d a f te r e ac h feed, as if le ft in situ f o r long p e rio d s it c a n cause la ry n g e a l o e d em a. T h e d is tu rb a n c e cau sed b y tu b e feeding m ay b e be n eficia l in th a t it m ak es th e p a tie n t c o u g h . In tra v e n o u s feeding is seldom necessary. (c) C a re o f the m o u th is v e ry im p o rta n t. T u b e -fe d ch ild re n e a s ily d e v e lo p s to m a titis, as d oes a child w ho lies w ith th e m o u th o p e n so t h a t the to n g u e b e co m es dry. (d) C o n s tip a tio n is a m u c h c o m m o n e r cause of v o m itin g th a n a n y o th e r. I f v o m itin g is cerebralif it is c o n tro lle d b y S te m e til su p p o s ito rie s oft in je c tio n . (e) H o u rly c h an g e s in p o sitio n h e lp to p re v e n t h y p o sta tic p n e u m o n ia and p re s s u re sores. I n h a ­ la tio n p n e u m o n ia is p re v e n te d b y ta k in g care w h en giving feeds a n d by q u ic k a tte n tio n a nd s u c tio n if v o m itin g o c cu rs. P n e u m o n ia is a v e ry c o m m o n cause o f d e a th in th e s e c h ildren. (f) R e g u la tio n o f b o d y te m p e ra tu re is esse n tia l. T he te m p e ra tu re m a y rise to 4 0 C ° o r fa ll to 33,3°C w ith g re a t ra p id ity . T h e h y p e r-p y re x ia is u su a lly a sso c ia te d w ith th e c o n v u ls io n s a n d h y p o ­ th e rm ia w ith c o m p le te im m o b ility o f th e p a tie n t. B o th e x tre m e s a re h a rm fu l. (g) O xy g en sh o u ld o n ly b e used w h e n th e p a tie n t w o u ld suffer if d e p riv e d o f it. I t s h o u ld be re m e m b e re d t h a t o x y g e n c au ses v a so -co n stric - tio n o f th e c e re b ra l v essels a n d m a y c au se c o m ­ p lete o c clu sio n o f a vessel a lre a d y in v o lv e d in the b a sa l e x u d a te . (h) G r e a t c a re sh o u ld be p a id to k e ep in g th e a irw ay c le ar. A ny u n c o n s c io u s p a tie n t is lia b le to s u f­ fo c a te if th e a irw a y b e co m es b lo c k e d b y se c re ­ tio n s, o r if th e to n g u e is a llo w e d to fa ll back. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) IVIAART 1977 F I S I O T E R A P I E 7 T h e s e p a tie n ts re q u ire c lo s e o b s e rv a tio n a n d m u st b e n u rs e d w ith th e h e a d e x te n d e d a n d tu rn e d to o n e side. (i) C o n v u lsio n s re q u ire im m e d ia te c o n tro l as they a re v ery e x h a u s tin g to th e p a tie n t. L u m in a l by m o u th o r in je c tio n o r sy ru p o f C h lo ra l a n d V a liu m a re m o st c o m m o n ly used. PH Y SIO TH ERA PY A t K in g G e o rg e V H o s p ita l, p h y s io th e ra p y , o c c u p a ­ tional th e ra p y a n d sc h o o lin g a re re g a rd e d as esse n tia l adjuncts to th e m ed ic al tre a tm e n t. It is n o t p o ssib le to f o rm u la te rig id p ro g ra m m e s o f physiotherapy b e c a u se tu b e rc u lo u s m en in g itis p ro d u c e s a wide ra n g e o f sy m p to m s w hich differ fro m c h ild to child- T h ese m ay ra n g e fro m a c o n sc io u s a n d r a tio n a l child w ith n o n e u ro lo g ic a l signs to a ch ild so deeply co m a to s e o r d e lirio u s as to b e a lm o s t in ac ce ssib le . In those w ith n e u ro lo g ic a l signs th e re m ay be h e m ip leg ia (w hich is u s u a lly rig h t sided), p a ra p le g ia , m o n o p le g ia , thetosis a n d lo ca lised o r g e n e ra lise d m u sc le tw itching. fhere m ay be so m e sp a stic ity a n d so m e flaccidity in th e ,ame c hild. T h e c h ild m ay a lso be b lin d , b u t it can recover sight, so it is n e ce ssa ry to w a tc h f o r a n y in d ic a ­ tions o f th e s e c h an g e s. Each p a tie n t m u st be c a re fu lly assessed in o rd e r to obtain a n d e v a lu a te th e clin ica l p ic tu re . T h e n , since th e sym ptoms a re so v a rie d a n d w ide s p re a d , tr e a tm e n t is mainly sy m p to m a tic a n d in b r o a d term s c onsists of keeping th e a irw a y c le ar, th e jo in ts m o ving a n d , w hen the m eningitis is re so lv e d , tre a tin g th e re s id u a l d isa b ili­ ties. F o r p ra c tic a l p u rp o se s i t is c o n sid e re d th a t th e patients c a n b e tre a te d as 'having a n a c q u ire d c e re b ra l palsy a n d th a t r e h a b ilita tio n s h o u ld e sse n tia lly b e alo n g functional lines. Acute Stage T he c hild is se rio u sly ill a n d p ro b a b ly u n c o n sc io u s. It should alw ay s b e b o r n e in m in d t h a t it is v e ry e asy to kill him . T h e p o s itio n o f th e h e a d is o f u tm o s t im p o rt­ ance— a p illo w s h o u ld n o t b e u se d — th e h e a d m u s t b e well e x te n d ed a n d tu rn e d to o ne side. I f th e ch in is allowed to c o m e o n to th e c h e s t th e ch ild c a n a n d w ill suffocate in a v e ry s h o r t tim e. T h e r e w ill b e n o stru g g le, no w a rn in g ; the ch ild will ju s t b e fo u n d d e ad in th e co t. T h e m o st w o rth w h ile aim s o f p h y s io th e ra p y in th is stage a re to — 1. M a in ta in j o in t ra n g e. K e e p th e c h e s t c le a r o f excessive secretions. M aintenance o f Joint Range A d a ily asse ssm e n t o f jo in t ra n g e sh o u ld b e m ade. G entle p assive m o v em e n ts a re given e v ery d a y in as full range as p o ssib le , e m p h a sis b e in g p la c e d o n a re a s w h e re it is a n tic ip a te d th a t c o n tra c tu re s m a y o c c u r, e.g. th e tendo-achilles a n d th e h a m s trin g m uscles b e c a u se o f th e “f ro g ” p o sitio n a d o p te d b y m a n y p a tie n ts . O fte n c h ild re n are a d m itte d w ith gro ss c o n tra c tu re s a n d w ith c a re fu l passive m o v em e n t th e s e a re u s u a lly c o rre c te d ; if n o t it may b e co m e n e c e ssa ry to a c c e p t th e situ a tio n , as w hen recovery o c cu rs th e d e fo rm ity m ay c o rre c t its e lf w hen the ch ild b e co m es a m b u la n t, o r if n o t it m a y u ltim a te ly require th e a tte n tio n o f th e o rth o p a e d ic su rg e o n . T h e re is a d a n g e r o f m yositis ossficans a n d a n y a c u te pain re a c tio n c alls f o r ra d io g ra p h ic in v e stig a tio n . I f it is found passive m o v em e n ts in th e a r e a a re d isc o n tin u e d . S p lin ta g e is n o t u su a lly a p p lie d in th is sta g e b e ca u se of p re s s u re p ro b le m s w hich o c c u r as a re s u lt o f th e in te rm itte n t spasm c a u s in g fric tio n b e tw e e n th e p a r t a n d splint. 2. Chest P hysiotherapy C h e st p h y s io th e ra p y c an be life saving in a c h ild w h o is h a v in g difficulty in c le a rin g sp u tu m . W ith p o s tu r a l d ra in a g e a n d c a re fu lly a p p lie d v ib ra tio n s , s p u tu m c a n be su c c essfu lly b ro u g h t to th e h ig h e r a re a s o f th e tra c h e a , w h e re it m ay c au se s p o n ta n e o u s c o u g h in g , o r it m a y b e su c tio n e d . O c c a sio n a lly o x y g e n -may be re q u ire d a n d th e in d ic a tio n s fo r its u se a re c y an o sis, e x tr e m e d y sp n o e a o f r e s p ira to ry o rig in o r in te rm itte n t re s p ir a tio n w ith d e te rio r a tio n in th e g e n e ra l c o n d itio n . C h ild re n re q u irin g o x y g e n a re n u rs e d in a n o x ygen te n t. I N T E R M E D IA T E S T A G E W h e n th e a c u te sta g e se ttle s a n d c o n sc io u n e ss re tu rn s th e in d ic a tio n s o n w h e th e r th e c h ild n e ed s f u r th e r p h y s io ­ th e ra p y b e c o m e a p p a re n t. S om e c h ild re n sh o w s p o n ­ ta n e o u s im p ro v e m e n t w ith r a p id r e tu r n o f fu n c tio n . O th e rs, h o w e v er, sh o w o b v io u s p h y s ic a l deficit a n d d a ily p h y s io th e ra p y is ne ce ssa ry . A sse ssm e n t u su a lly re v e a ls th a t th e c h ild h a s lo st its la te r p a tte rn s of m o v e m e n t a n d h a s r e tu r n e d to a n e a rlie r reflex stage. T h e y do n o t a lw ay s e x h ib it th e ty p ic a l p a tte rn s o f sp a stic ity a sso c ia te d w ith c e re b ra l p a lsy . F o r e x a m p le , in p la c e o f th e u su a l a d d u c to r sp a sm th e s e c h ild re n a re o fte n a b d u c te d a t th e hip. M a n y o f th e c h ild re n a re hem ip leg ic. T o n ic reflexes a re n o t as a p p a r ­ e n t as in th e m o re c o n v e n tio n a l c e re b ra l p a ls ie d c h ild , th o u g h p rim itiv e re sp o n se s su c h as th e M o r o re a c tio n m a y still be p re s e n t in a c hild, w ho, b u t fo r b e in g u n c o n sc io u s , w o u ld n o rm a lly h a v e g ro w n th ro u g h th is stage. T h e p h y s io th e ra p is t’s aim s a re to in h ib it a b n o rm a l m o v e m e n t p a tte rn s a n d to fa c ilita te a u to m a tic re a c tio n s in o rd e r t h a t th e c h ild m a y e x p e rie n c e th e p a tte rn s o f m o v e m e n t a sso c ia te d w ith n o rm a l d e v e lo p m e n t. T h e s e a im s a re a ch iev e d in re sp o n se to th e p h y s io th e ra p is t’s h a n d lin g a n d p o sitio n in g o f th e c h ild . T h e B o b a th n e u ro -d e v e lo p m e n ta l a p p r o a c h to th e ra p y h as b e en fo u n d to be v e ry u s e fu l in th e m a n a g e m e n t o f th e s e c h ild re n , th o u g h , d ue to th e d iv ersity o f sy m p ­ tom s, th e a p p r o a c h is e sse n tia lly eclectic. It sh o u ld be re m e m b e re d th a t in th is sta g e th e ch ild is still q u ite ill a n d tre a tm e n t p e rio d s m ay h a v e to be v e ry s h o r t a t first a n d p ro g re s se d in le n g th a s th e c h ild im p ro v e s. I f th e ch ild is irrita b le , tr e a tm e n t s h o u ld b e a b a n d o n e d f o r th e day. T re a tm e n t is d ire c te d to in itia lly o b ta in in g h e a d c o n ­ tro l, w hich is th e m o st im p o rta n t f a c to r in th e d e v e lo p ­ m e n t o f all o th e r fu n c tio n s such as e y e -h a n d c o n tro l, v isual acu ity , ro llin g a n d b a la n c e . R o llin g fro m supine, first o v e r th e a ffected side a n d th e n o v e r th e u n a ffe c te d side, in th e c ase o f a h e m ip leg ic, is o b ta in e d b y th e a p p r o p ria te te c h n iq u e s o f h a n d lin g . I n th e p ro n e p o sitio n w e ig h t b e a rin g is o b ta in e d in th e u p p e r lim b s, first in th e fo re a rm s u p p o rt p o sitio n , w h e re w eight tra n s fe re n c e fro m side to sid e is e n c o u ra g e d . T h is is fo llo w e d by re a c h in g o u t w ith o n e a rm ; th is n e ce ssitate s w e ig h t b e a rin g o n o n e lim b w h ilst e n c o u ra g in g t r u n k r o ta tio n . L a te r, w e ig h t b e a rin g is o b ta in e d o n e x te n d e d a rm s. A s th e c h ild p ro g re sse s sittin g b a la n c e is o b ta in e d , first w ith s u p p o rt fro m th e th e ra p is t a n d th e n w ith th e a r m s in th e fo rw a rd s u p p o rtin g p o sitio n . W e ig h t b e a rin g is th e n e n c o u ra g e d in sittin g w ith the a rm s b y th e side. A t th is sta g e o f sittin g th e ch ild is e n c o u ra g e d to s i t u p in its c o t h o ld in g o n to th e b a rs. A f t e r th e “ a ll f o u r s ” p o sitio n h as b e e n a ch iev e d , c ra w lin g is e n c o u ra g e d ; p ro g re s sio n is th e n m ad e to k n e e lin g , sta n d in g a n d w a lk in g . U n lik e in th e c e re b ra l p a lsie d c h ild , re sp o n se to tr e a t ­ m e n t a n d re c o v e ry o f fu n c tio n in th e c h ild w ith tu b e r ­ c u lo u s m e n in g itis is f re q u e n tly ra p id . T h is is m o st likely d u e to th e f a c t t h a t th e c h ild m a y b e a lre a d y g ro w n th ro u g h th e “ m ile sto n e s” o f n o r m a l d e v e lo p m e n t b e fo re th e o n se t o f th e illness, w h e re a s th e c e re b ra l p a ls ie d ch ild has n e v e r e x p e rie n c e d m a n y o f th e s e . I n a d d itio n , th e n a tu re o f th e b ra in d y s fu n c tio n in tu b e rc u lo u s m en in g itis is tra n s ie n t in a b o u t 50% o f th e p a tie n ts w h o re c o v e r. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 8 P H Y S I O T H E R A P Y M A RCH , 1977 P assive m o v e m e n ts a re c o n tin u e d if th e re is still the p o ss ib ility o f c o n tra c tu re s o c c u rrin g . P o s itio n in g a n d m o v e m e n ts a re b e tt e r th a n sp lin tin g , e sp e cially w h e re sp a sticity is p re s e n t, b e ca u se o f th e d a n g e r o f p re ssu re so re s, b u t tra c tio n , p la s te r o f p a ris o r p la s ta z o te m a y be used w ith c a re . C O N V A L E S C E N T S T A G E T h e ch ild is tra n s fe rre d to th e c o n v a le s c e n t w a rd a t th e stage o f p ro g re s s w h en it is n o lo n g e r d istresse d by n o ise , w h e n n o fu r th e r sp e c ia l n u rs in g is re q u ire d a nd w h e n it is c o n sid e re d t h a t c o n ta c t w ith o th e r c h ild re n w ill b e beneficial. P h y s io th e ra p y is c o n tin u e d a lo n g th e lines d e scribed a n d is a im e d a t o b ta in in g th e o p tim u m fu n c tio n a l a b ility in e ac h c h ild . W h ilst a n u m b e r o f th e c h ild re n le a rn to w a lk sa tis fa c to rily w ith o u t a p p lia n c e s, so m e do n e ed c a li­ p e rs o r sp e c ia l b o o ts to h o ld th e f o o t in a b e tte r p o s itio n in o r d e r to d e v e lo p a n a c c e p ta b le g ait. In th e sm a ll p ro p o r tio n o f c h ild re n w h o a re p a ra p le g ic , tre a tm e n t is d ire c te d to s tre n g th e n in g th e m uscles o f the tru n k , sh o u ld e r g ird le a n d ' u p p e r lim b s a n d te a c h in g fu n c tio n a l m o v e m e n ts su c h as b e d m o b ility a n d tra n s fe r a ctivities. T h o s e w h o a re a b le , a re g iv en g a it r e tra in in g a n d w h e e lc h a ir a ctivities. O C C U P A T IO N A L T H E R A P Y O c c u p a tio n a l th e ra p y is given to a ll c h ild re n b u t m a in ly to th o s e w h o c a n n o t a tte n d sc h o o l. I t consists chiefly o f p la y th e ra p y , h a n d c ra ft a ctiv ities a n d th e use o f e d u c a tio n a l toys. SC H O O L IN G A ll c h ild re n o f a b o u t f o u r y ears a n d a b o v e a n d w ho a re a b le , a tte n d s c h o o l in th e c o n v a le s c e n t w a rd . T he lessons a re c o n d u c te d b y a te a c h e r w h o is a lso a p a tie n t a n d she a rra n g e s th e lesso n s to fit in w ith h e r o w n tr e a t ­ m e n t a n d re st p e rio d s . T h e c h ild re n receive a b o u t th re e h o u rs sc h o o lin g a d a y , h a lf in th e m o rn in g a n d h a lf in th e a fte rn o o n . A lth o u g h th e sc h o o l is e sse n tia lly a lo n g th e lines o f n u rs e ry sc h o o lin g ; th e c h ild re n a re ta u g h t re a d in g , w ritin g a n d sim p le a rith m e tic . Singing is also a p o p u la r f e a tu re . T h is sc h o o lin g in h o s p ita l does h e lp to p re p a re th e y o u n g e r ch ild f o r n o r m a l sc h o o l w h e n its tre a tm e n t is e v e n tu a lly c o m p le te d . A F T E R C A R E A ll c h ild re n w ith tu b e rc u lo u s m e n in g itis h a v e e ig h te e n m o n th s o f su p e rv ise d tre a tm e n t; th is in clu d e s th e tim e s p e n t in th e h o s p ita l a n d th e T .B . se ttle m e n t. S pecific tre a tm e n t, i.e. l.N .A .H . (N e o te b e n ), is c o n ­ tin u e d b y in je c tio n u n til th e w ard siste r is satisfied th a t th e c hild c a n sw a llo w p ro p e rly a n d th e d o c to r is satisfied t h a t the d ru g is b e in g a b s o rb e d ; th e r e a f te r th e d ru g is given b y m o u th o n c e a day. S e v e rely h a n d ic a p p e d c h ild re n stay in h o s p ita l to c o n ­ tin u e th e ir tr e a tm e n t b u t th o se w ho c a n m o v e a ro u n d a n d a re a b le to c a re fo r th em se lv es a re tra n s fe rre d to a T .B . se ttle m e n t. L u m b a r p u n c tu r e a n d c e re b ro -s p in a l fluid a n a ly sis is c a rrie d o u t fo r o n e y e a r a fte r th e s ta r t o f th e specific tre a tm e n t a n d , a fte r tra n s f e r to th e se ttle m e n t, th e c h ild ren re tu rn to h o s p ita l a t fo rtn ig h tly a n d th en m o n th ly in te rv a ls f o r th is. C h ild re n n e e d in g re n e w a l o f a p p lia n c e s o r o rth o p a e d ic c o n s u lta tio n a re seen in th e h o s p ita l clinics a n d any c o rre c tiv e su rg e ry t h a t is re q u ire d is c a rrie d o u t a t K in g G e o rg e V H o s p ita l o r a n y c o n v e n ie n t h o s p ita l in th e v icinity o f th e se ttle m e n t. T h e re is g o o d lia iso n b e tw e e n th e h o s p ita l physi0_ th e ra p is t a n d th e n u rse s a t th e s e ttle m e n t a n d a n y sim ple p h y s io th e ra p y p ro c e d u re s w h ic h a re still re q u ire d are c a rrie d o u t b y th ese nurses. S c h o o lin g c o n tin u e s in th e s e ttle m e n t a n d w hen the c h ild ’s tr e a tm e n t is c o m p le te d he is g iv en a tr a n s f e r card w h ic h a llo w s d ire c t e n try in to h is lo c a l sc h o o l w ithout h a v in g to w a it f o r a n e w te rm to begin. T h e se v e re ly h a n d ic a p p e d c h ild re n re m a in in hospital u n til th e ir tre a tm e n t is c o m p le te d . T h e y a re th e n usually d isc h arg e d in to th e care o f th e ir p a re n ts . I f a c hild is b a d ly m e n ta lly h a n d ic a p p e d th e p a r e n ts receive a single c a re fin a n c ia l g ra n t to e n a b le th e m to k e e p th e child at h o m e. O ld e r se verely h a n d ic a p p e d c h ild re n m ay h a v e to be a d m itte d to c h ro n ic sick h o s p ita ls o r m e n ta l h o spitals J u d g in g fro m the re su lts a t K in g G e o rg e V H o s p ita l, it is e stim a te d fro m th e n o tified c ases alon-j in th e R epublic o f S o u th A fric a , i.e. 409 in 1974, a n d m o stly b lac k , that o v e r o n e h u n d re d c h ild re n die in h o s p ita l a n d o ver one h u n d re d a n d fifty b e c o m e m e n ta lly a n d /o r physical^ h a n d ic a p p e d e ac h y e ar. H o w e v e r th e p ro b le m is probabl- g re a te r th a n it seem s. I t h a s b e e n n o te d t h a t somj c h ild re n w ho h a v e a p p a re n tly re c o v e re d c o m p le te ly witl n o o b v io u s p h y sic a l o r m e n ta l deficit sh o w em o tio n a p ro b le m s o v e r a n d a b o v e th o se fo u n d in n o r m a l children T h e y lose th e ir te m p e r q u ic k ly a n d fig h t w ith othe c h ild re n , w h ic h c re a te s difficulties a t sc h o o l, w h e re thei m a y fa il th e ir first tw o y e ars. E v e n tu a lly th e ir em ploy m e n t o p p o rtu n itie s m ay b e im p a ire d d u e to th e ir quicl te m p e r, fo rg e tfu ln e s s a n d lac k o f re sp o n sib ility . T h e m a n a g e m e n t o f tu b e rc u lo u s m en in g itis as carried o u t a t th e K in g G e o rg e V H o s p ita l, D u r b a n , h as been p re se n te d . T h e re is n o d o u b t th a t th e m a n y problem s ra ised b y th is la rg e ly p re v e n ta b le d isease a d d significantly to th e lo a d o f th e o v e rw o rk e d a n d u n d e rm a n n e d m edical services in th e R e p u b lic . T h e g o v e rn m e n t a n d lo c a l a u th o ritie s a re d ep lo y in g a la rg e p r o p o r tio n o f th e ir fin a n c ia l a n d m a n p o w e r re­ so u rc e s in c o m b a tin g tu b e rc u lo s is. H o w e v e r it seem s th at th e p o p u la tio n as a w h o le is n o t y e t sufficiently a w a re of th e im p lic a tio n s o f th is e v e r-p re se n t disease. O n ly a v ig o ro u s h e a lth e d u c a tio n c o m p a ig n a n d c o n tin u a n c e of p la n to o p e n m a n y m o re clinics so th a t tre a tm e n t centres a re w ith in easy re a c h o f p a tie n ts a n y w h e re , w ill b rin g it u n d e r c o n tro l a n d , h o p e fu lly , lead to its e v e n tu a l e rad i­ catio n . R E F E R E N C E S 1. L in c o ln , E. M ., a n d Sew ell, E . M . (1963), T u b e rc u lo s is in C h ild re n — M c G ra w H ill, N e w Y o rk . 2. S o u th A fric a (R e p u b lic ) D e p a r tm e n t o f H ealth. A n n u a l R e p o r t (1974). 3. T u b e r c u lo u s M e n in g itis in C h ild re n . B ritish M edical J o u r n a l (1971) 1, 1-2. A C K N O W L E D G M E N T S I w ish to a c k n o w le d g e th e D e p a r tm e n t o f H e a lth for p e rm iss io n to p re s e n t th is p a p e r a t th e R e g io n a l C ongress o f th e C o m m o n w e a lth M e d ic a l A s so c ia tio n h eld in M a s e ru , L e s o th o , in O c to b e r 1975 a n d a ls o fo r p erm ission fo r its p u b lic a tio n . M y th a n k s a re due to D r. W . C . M . B u lk ele y , Mrs. E. B o o th a n d M rs. J. C u rrie o f th e K in g G e o rg e V H o s p ita l, D u rb a n , f o r th e ir h e lp a n d e n c o u ra g e m e n t in p re p a rin g th is p a p e r. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )