systemic lupus erythematosus ( sle ) is associated with significant cerebrovascular and 
 neuropsychiatric diseases for which multiple pathogeneses have been proposed1 .
involvement of the central nervous system 
 ( cns ) is one of the major causes of mortality and morbidity in sle patients2 .
although the underlying mechanisms of the 
 cns involvement are a less understood aspect of the disease , the common etiology is the 
 involvement of the cerebral microvasculature that causes deficits in motor functions shown 
 in the other diseases involving the cns3 . 

cerebrovascular diseases in sle have been estimated to occur in 5 to 19.6% of sle 
 patients4 .
sle patients with cns 
 involvement can demonstrate stroke - like symptoms such as severe hemiparesis , spasticity , 
 loss of soft tissue elasticity , etc1 , 5 .
previous studies reported 
 that a corticosteroid treatment improved neurological symptoms by normalization of regional 
 cerebral blood flows for sle patients with neuropsychiatric manifestations9 .
however , no studies have been reported that 
 corticosteroid intervention led to reduced spasticity , improved balance and adl for sle 
 patients with cns involvement .
these facts indicate that although corticosteroid 
 intervention could be a major approach to promote relief of symptoms in sle patients , 
 intervention has been limited to active and directive intervention to improve the motor 
 function of patients .
motor functions , such as reduced spasticity , balance , gait , and adl , 
 in sle are important because improvement of motor functions in patients leads to a better 
 quality of life .
physical therapies have been a major treatment used to improve motor functions for patients 
 with cns problems10 .
a main concept for 
 such physical therapy methods is developing inhibition of abnormal motor synergies to 
 decrease spasticity and improve motor control abilities in such patients11 , 12 .
these signify that physical therapy treatments might play an 
 important role in improving decreased motor functions for sle patients with cns involvement . 

however , based on our literature searches of pubmed and google 
 scholar , surprisingly , no studies have been reported about physical therapy 
 applied to sle patients with cns involvements . in our study
we 
 applied physical therapy as well as corticosteroid therapy to the patient and investigated 
 the clinical pathway .
we conclude that these interventions can be effective treatments for 
 functional improvement of the patient .
a 22-year - old man with sle was admitted to our physical therapy department , and he signed 
 an informed consent statement for this study . the patient presented with utterance of 
 meaningless words , jaundice , and lower limb weakness .
he had been diagnosed with discoid 
 lupus erythematosus , febrile neutrophilic dermatosis , schizophrenia , and bipolar affective 
 disorder five months prior to presentation .
he reported a four - day history of epigastric 
 pain ; four days before , there had been no other systemic features of infection .
a radionuclide 
 regional cerebral blood flow ( rcbf ) study with 900 mbq technetium-99  m ethyl cysteinate 
 dimer ( tecd ) by single - positron emission computed tomography ( spect ) revealed multifocal 
 decreased perfusion to the anterior cingulate , left parietal , left occipital , right 
 lateral temporal , and anterior pole of the left temporal cortices .
ultrasound revealed 
 that the liver , spleen , pancreas , and gall bladder were normal in size , contour , 
 echogenicity , wall thickness , and calcification .
a hematological examination indicated 
 that his hemoglobin , hematocrit , red blood cells , white blood cells , and platelets were 
 normal .
however , in a liver function test , his ast , alt , alp , and bilirubin levels were 
 markedly elevated .
he was also positive for anti - dsdn , anti - histone , and anti - sm 
 antibodies .
electromyography showed no abnormal spontaneous activity , and his motor unit 
 potential was of normal amplitude and duration .
he was treated with high - dose intravenous 
 steroids ( methylprednisolone ; 1  g / day ) , which resulted in complete resolution of the sle . 

after admission for three days , he requested physical therapy due to marked spasticity 
 that was uncontrollable by corticosteroid intervention .
his spasticity was similar to a 
  bilateral stroke - like  symptom presented in his trunk and all four limbs .
when admitted 
 to physical therapy on the day of the request , his spasticity level was modified ashworth 
 scale ( mas ) grade 3 in both lower limbs and grade 2 in both upper limbs .
we could not evaluate his balance ability and adl 
 level at the time of referral .
his outcome measurements were evaluated at the time of 
 referral and at 5 days , 7 days , 12 days , and 16 days later ( fig .
schedule of treatment and assessment our first goal of the therapeutic treatment for the patient was spasticity relief , since 
 he had increased muscle tone that deteriorated motor function ( fig .
1 ) . we used the reflex inhibition pattern ( based on the bobath 
 concept ) to reduce the spasticity level9 .
the reflex inhibition pattern could be described as particular 
 movement patterns of proximal joints that affect the tone of the trunk and limbs .
the 
 applied reflex inhibition techniques to the patient consisted of passive and active rom 
 exercises in all four limbs and the trunk in a normal sitting posture while the hip and 
 shoulder joints were flexed at 90 degrees . these techniques were applied for 1 hour a day 
 ( 5 days / week ) . after five days of treatment ,
his spasticity decreased to an mas grade of 2 
 in the lower limbs and 1 + in the upper limbs .
these outcomes suggest that spastic muscle groups were successfully inhibited 
 by the applied physical therapy techniques .
after seven days of reflex inhibition pattern treatment , his spasticity was no longer 
 apparent .
we evaluated his balance ability with the berg balance score ( bbs ) , and his bbs 
 at this time was 15 , indicating that the level of walking with assistance was not 
 achieved13 ( fig .
1 ) . he could maintain a sitting and standing posture with 
 minimal assistance from a physical therapist .
for these reasons , we decided to focus the 
 physical therapy intervention on improvement of balance beginning with the intervention on 
 the 8th day of the physical therapy session ( fig . 
 1 ) .
he was instructed to reach as far as possible in all cardinal directions in a 
 sitting posture in an unsupported chair and carry out active range of motion activities . 

he was also asked to maintain a normal standing position on his own base of support .
these 
 techniques were applied for 1 hour a day ( 5 days / week ) . after a week
, he could perform the 
 sitting unsupported and partially perform the sitting to standing , standing to sitting , 
 and transfers items of the bbs .
twelve days after the request for physical therapy , his 
 bbs score reached 33 points , indicating the level of walking with assistance13 ( fig . 
 1 ) .
we then set independent walking as his new goal and started gait training on 
 the 13th day of the physical therapy intervention ( fig . 
 1 ) .
after sixteen days , that is , on the last day of his physical therapy sessions , he could 
 walk without a cane .
his bbs score also reached 47 points , indicating the level of 
 independent walking13 ( fig .
a 22-year - old man with sle was admitted to our physical therapy department , and he signed 
 an informed consent statement for this study . the patient presented with utterance of 
 meaningless words , jaundice , and lower limb weakness .
he had been diagnosed with discoid 
 lupus erythematosus , febrile neutrophilic dermatosis , schizophrenia , and bipolar affective 
 disorder five months prior to presentation .
he reported a four - day history of epigastric 
 pain ; four days before , there had been no other systemic features of infection .
a radionuclide 
 regional cerebral blood flow ( rcbf ) study with 900 mbq technetium-99  m ethyl cysteinate 
 dimer ( tecd ) by single - positron emission computed tomography ( spect ) revealed multifocal 
 decreased perfusion to the anterior cingulate , left parietal , left occipital , right 
 lateral temporal , and anterior pole of the left temporal cortices .
ultrasound revealed 
 that the liver , spleen , pancreas , and gall bladder were normal in size , contour , 
 echogenicity , wall thickness , and calcification .
a hematological examination indicated 
 that his hemoglobin , hematocrit , red blood cells , white blood cells , and platelets were 
 normal .
however , in a liver function test , his ast , alt , alp , and bilirubin levels were 
 markedly elevated .
he was also positive for anti - dsdn , anti - histone , and anti - sm 
 antibodies .
electromyography showed no abnormal spontaneous activity , and his motor unit 
 potential was of normal amplitude and duration .
he was treated with high - dose intravenous 
 steroids ( methylprednisolone ; 1  g / day ) , which resulted in complete resolution of the sle . 

after admission for three days , he requested physical therapy due to marked spasticity 
 that was uncontrollable by corticosteroid intervention .
his spasticity was similar to a 
  bilateral stroke - like  symptom presented in his trunk and all four limbs .
when admitted 
 to physical therapy on the day of the request , his spasticity level was modified ashworth 
 scale ( mas ) grade 3 in both lower limbs and grade 2 in both upper limbs .
we could not evaluate his balance ability and adl 
 level at the time of referral .
his outcome measurements were evaluated at the time of 
 referral and at 5 days , 7 days , 12 days , and 16 days later ( fig .
schedule of treatment and assessment our first goal of the therapeutic treatment for the patient was spasticity relief , since 
 he had increased muscle tone that deteriorated motor function ( fig .
1 ) . we used the reflex inhibition pattern ( based on the bobath 
 concept ) to reduce the spasticity level9 .
the reflex inhibition pattern could be described as particular 
 movement patterns of proximal joints that affect the tone of the trunk and limbs .
the 
 applied reflex inhibition techniques to the patient consisted of passive and active rom 
 exercises in all four limbs and the trunk in a normal sitting posture while the hip and 
 shoulder joints were flexed at 90 degrees . these techniques were applied for 1 hour a day 
 ( 5 days / week ) .
after five days of treatment , his spasticity decreased to an mas grade of 2 
 in the lower limbs and 1 + in the upper limbs .
these outcomes suggest that spastic muscle groups were successfully inhibited 
 by the applied physical therapy techniques .
after seven days of reflex inhibition pattern treatment , his spasticity was no longer 
 apparent .
we evaluated his balance ability with the berg balance score ( bbs ) , and his bbs 
 at this time was 15 , indicating that the level of walking with assistance was not 
 achieved13 ( fig .
1 ) . he could maintain a sitting and standing posture with 
 minimal assistance from a physical therapist .
for these reasons , we decided to focus the 
 physical therapy intervention on improvement of balance beginning with the intervention on 
 the 8th day of the physical therapy session ( fig . 
 1 ) .
he was instructed to reach as far as possible in all cardinal directions in a 
 sitting posture in an unsupported chair and carry out active range of motion activities . 

he was also asked to maintain a normal standing position on his own base of support .
these 
 techniques were applied for 1 hour a day ( 5 days / week ) .
after a week , he could perform the 
 sitting unsupported and partially perform the sitting to standing , standing to sitting , 
 and transfers items of the bbs .
twelve days after the request for physical therapy , his 
 bbs score reached 33 points , indicating the level of walking with assistance13 ( fig . 
 1 ) .
we then set independent walking as his new goal and started gait training on 
 the 13th day of the physical therapy intervention ( fig . 
 1 ) .
after sixteen days , that is , on the last day of his physical therapy sessions , he could 
 walk without a cane .
his bbs score also reached 47 points , indicating the level of 
 independent walking13 ( fig .
in this study , corticosteroid and physical therapy interventions were applied to an sle 
 patient with cns involvement . at the time of referral
, he showed no active motion and a high 
 level of spasticity in all four limbs .
after 16 days of treatment , the patient demonstrated 
 stabilized and alleviated neurological symptoms and an improved functional level .
thus , the 
 current results indicate that the corticosteroid and physical therapy interventions applied 
 to the present patient effectively recovered his neurological symptoms and motor 
 functions .
our first clinical goal was to reduce the patient s spasticity level because his high level 
 of spasticity inhibited normal movement patterns .
although the mechanisms underlying 
 spasticity have not been fully elucidated , prior works suggest that reflex inhibition and 
 decreased reciprocal inhibition of motor neurons may make an important contribution14 , 15
. the reflex and reciprocal inhibition techniques used in this study 
 might allow breakdown of the abnormal spinal stretch reflex mechanism and return of 
 appropriate muscle activity .
another important reason to reduce the spasticity was that it is a starting point to 
 facilitate functional activities16 .
this 
 was the reason why balance and gait training were provided to the patient at the time when 
 spasticity was no longer apparent17 .
the 
 results from the present case show that functional training seems to be successful in 
 recovering balance and gait abilities in a fast and effective manner , consistent with other 
 studies18 , 19 .
ultimately , he was discharged from the hospital with the ability 
 to walk independently after sixteen days of physical therapy sessions .
one of the limitations of the present case study is that it is unclear whether the 
 patient s spasticity and motor function recovery were primarily due to the corticosteroid 
 intervention or the physical therapy intervention .
based on previous studies , however , the 
 corticosteroid intervention was primarily administered to stabilize and alleviate the 
 patient s neurological symptoms6,7,8 , and there was no 
 evidence of functional recovery .
although it is hard to differentiate the effects of the 
 corticosteroid and physical therapy interventions , we conclude that the two interventions 
 interplayed with each other to improve the patient s clinical status . specifically , the 
 present impressive recovery in the patient s functional abilities resulted largely from the 
 physical therapy intervention , while the corticosteroid treatment had an effect on 
 stabilization and alleviation of the neurological symptoms .
further studies may be needed to 
 evaluate the possible differences between corticosteroid interventions and physical therapy 
 interventions in the treatment of sle patients with cns involvement .
 [ purpose ] systemic lupus erythematosus ( sle ) is a chronic , immune - mediated disease , 
 affecting 0.1% of the general population . to date , few studies have investigated the 
 efficacy of physical therapy for sle patients with cns involvement . 
 the aim of this study 
 was to report whether the combined use of corticosteroids and physical therapy , consisting 
 of reflex inhibition and functional training , was beneficial to functional recovery . 
 
 [ subjects and methods ] a 22-year - old male sle patient with cns involvement requested 
 physical therapy due to strong spasticity of the trunk and limbs in a bedridden state . 
 corticosteroid intervention and physical therapy 
 were undertaken for 16 days . 
 [ result ] 
 after 16 days of the interventions , the patient demonstrated stabilized and alleviated 
 neurological symptoms and an improved functional level . 
 [ conclusion ] the present case 
 indicates that physical therapy combined with corticosteroids might be a possible 
 treatment and rehabilitation method to effectively recover motor function for sle patients 
 who have strong spasticity due to cns involvement . 
INTRODUCTION
CASE REPORT
Patient
Physical therapy
DISCUSSION