The patient was a 17-year-old Nigerian male who was admitted to the children’s emergency ward of our health care facility following complaints of jerking and inability to move the lower limbs 6 days before admission. The patient was apparently healthy until he experienced a high grade fever, for which he took paracetamol tablets. He was then taken to a nearby health center the next day, where he also received Amatem and Neurovit Forte tablets, and intramuscular injections of Paluther and diclofenac. This was followed by the passage of dark-brown urine later in the day. Five days later, the patient started limping on the right lower limb. This was followed by an insidious and progressively worsening jerking movement of both lower limbs, which later spread to the entire body. The patient could not walk thereafter and preferred to lie down most times. Following the worsening of the above symptoms, the patient was brought to the general outpatient clinic of our hospital 2 days later, and was advised by the physician to use cold compress to manage the frequent jerking movement. With the persistence of symptoms, the patient was brought back to the general outpatient clinic after a further 2 days. He was then placed on Redflex, pregabalin, diclofenac and Neurovit Forte tablets and Neurogesic (topical analgesic) cream by the physician. However, he was brought to the children’s emergency ward after another 2 days with worsening fever, where he was admitted. While on admission, patient developed high blood pressure (160/100 mmHg). He was also placed on medications for high blood pressure, infection, and inflammation by the attending medical team, including amlodipine, ceftriaxone, diazepam, phenobarbitone, dexamethasone, and tinidazole. The physiotherapy team was invited 3 days after his admission into the children’s emergency ward for physical rehabilitation. The patient appeared to be an intelligent secondary school leaver, who had written the first phase of his university entrance examination and was awaiting the second and last phase, which had been delayed due to the COVID-19 lockdown. His leisure activities included swimming and gym workouts. He was vibrant and led a good social life. The patient was met lying prone, sweating profusely, and in obvious physical and emotional distress. On observation, he was febrile to touch, acyanozed and anicteric, with no peripheral edema and in no obvious respiratory distress. He had an intravenous cannula on the right forearm and a urinary catheter was in situ. The patient was also wearing diapers, but noted that he was continent to both urine and feces. The patient experienced intermittent severe spasm and jerking of the lower limbs. He was conscious, alert, and oriented in time, place, and person, but he was looking worried and anxious. The patient was really worried and concerned about the potential impact his condition would have on his chances of getting admitted to and attending the university. He needed assurances from our team on his chances of walking again and gaining total independence in performing his activities and instrumental activities of daily living. His vital signs were 140/90 mmHg blood pressure, 84 beats per minute (bpm) pulse rate, 30 cycles per minute respiratory rate, and 38 °C temperature. On physical examination, the patient complained of pain in the lower back and left gluteus, with a rating of 5/10 on the verbal pain rating scale. Physical assessment of the upper limbs showed no abnormality at all. However, the lower limbs showed some abnormalities. The patient presented with increased muscle tone, spasm, and spasticity, reduced active and passive range of movements, and fixed plantar flexion in the left ankle with Achilles’ tendon tightness. He also had exaggerated deep tendon reflexes and tested positive to Babinski reflex with clonus bilaterally. Furthermore, he experienced a shocking sensation bilaterally when touched from the T12 spinal level downwards. Gross muscle strength, measured with the Oxford grading system, was reduced bilaterally. Differential diagnoses included transverse myelitis, Guillain–Barré Syndrome (GBS), disc herniation, spinal stenosis, spinal epidural/subdural hematoma, and spinal tumor that could explain the lack of any sign of inflammation on the spinal magnetic resonance imaging. Having ruled out the differential diagnoses, further investigations were conducted to make the final diagnosis. A brain and spine MRI was carried out 10 days after admission. Brain MRI returned normal. Spinal MRI showed no sign of inflammation on any spinal segment and was also used to rule out disc herniation, spinal tumor or stenosis, and spinal epidural/subdural hematoma. In a multidisciplinary team meeting that included the pediatricians, radiologists, pediatric physiotherapists, pharmacists, and nurses, wide consultations and discussions were held. It was agreed that since the MRI was conducted almost 21 days after the patient’s symptoms started, and the patient had taken some antibiotics, antiinflammatory medications, and corticosteroids while on admission, this must have resolved the inflammation in the spinal cord. The patient’s history and clinical presentations, which were typical of transverse myelitis, were heavily relied upon to make the final diagnosis of acute transverse myelitis. Our immediate goals, in agreement with the patient’s family, were to reduce pain and the frequent muscle spasms (with jerking movements) experienced by the patient and prevent further physical deterioration. In the medium term, we planned to normalize muscle tone and improve joint range of motion. In the long term, we planned to strengthen the affected muscles and improve functional independence. The patient was seen twice a day by the pediatric physiotherapists during the week (Mondays to Fridays), during the morning ward rounds, and during the evening call duty. At the weekends (Saturdays and Sundays), the patient was seen once a day during call duty. To achieve the immediate goals, we positioned the patient’s trunk to relieve pressure off the low back, to reduce the low back and gluteal pain. This was achieved by placing a firm pillow under the patient’s thighs in a supine lying position. The patient was also placed on an improvised splint using a crepe bandage on the left foot to correct the fixed plantar flexion. To reduce muscle spasm, we commenced cryotherapy using ice cubes wrapped in a clean towel, 30 minutes, twice per day. After the cryotherapy, gentle stroking was applied to the muscles of the thighs and legs. This was applied slowly in straight line, from proximal to distal, with the tips of the fingers. For the medium-term goals, soft tissue mobilization and sustained gentle passive stretches were introduced to normalize muscle tone. Kneading and wringing techniques were applied to every muscle group of the lower limbs, with more attention given to the left lower limb with considerably more hypertonicity. Sustained gentle passive stretches were applied to all joints of the lower limbs, targeting every muscle group. Passive mobilization was also commenced to improve the joint range of movement. Free active and resisted exercises were subsequently commenced, targeting all muscle groups, starting from the proximal to the distal muscle groups in an alternate manner, right to left and back to right for each muscle group. Resistance was provided manually by the therapist’s hands. Functional retraining focused on bed mobility exercises, including rolling from side to side, lower trunk rotation, bridging exercises, curl-up exercises, stepping and standing exercises, and squatting and walking exercises. A flowchart of the rehabilitation process is shown in Fig. (rehabilitation approach) Proper positioning of the low back and pelvis by placing a firm pillow under the thighs with the patient in supine lying relieved the patient’s low back and gluteal pain after 3 days (verbal pain rating scale 0). However, the patient was advised to maintain this position while lying supine as long as he was admitted to avoid reoccurrence of pain. Cryotherapy and gentle stroking reduced the frequency and intensity of muscle spasm after 5 days, with no spasm on the right lower limb and less frequent (less than one every 30 minutes) and less intense spasm on the left lower limb. The line of management was continued and the interventions for the medium-term goals were introduced. Soft tissue mobilization (kneading and wringing) and sustained gentle passive stretches were introduced after 5 days to normalize the patient’s muscle tone. These were combined with previous interventions of proper positioning, cryotherapy, and gentle stroking. After 3 days of the combined interventions, the patient’s muscle tone reduced. On assessment by the modified Ashworth scale, the patient had 0 on the right lower limb, 1+ on the left hip, and 3 on the left knee and left ankle. Hence, the patient could achieve full active range of movement on all the joints of the right lower limb, and could move the right lower limb without difficulty. On the left hip, the patient could achieve a mid range of movement actively and a full range of movement passively. On the left knee and left ankle joints, the patient could only achieve just a small range (approximately 20°) actively, but a full range could be achieved passively with great difficulty. The patient also reported that the shocking sensation felt below T12 level when touched had reduced from 8/10 to 3/10 on the verbal rating scale. After a further 3 days of treatment, spasticity was reassessed on the left lower limb. The modified Ashworth scale score for the left hip was 0, 1+ for the left knee, and 2 for the left ankle. The patient could achieve full active range of movement on the left hip, mid range on the left knee, and below mid range on the left ankle. On passive movement, patient could achieve full range of movement on all joints but with more difficulty on the left ankle. Muscle strength for each muscle group of the lower limbs was evaluated using the Oxford muscle grading scale. The scores are presented in Table. Consequently, free active and resisted exercises were commenced for both lower limbs and were maintained till the patient was discharged. Bed mobility exercises were also introduced. After 3 days of intensive strengthening exercises, the patient commenced standing and stepping, squatting, and gait retraining. All the above exercises were performed with a Zimmer frame and support from the physiotherapists. Initially, the patient walked short distances but progressed to longer distances as the days went by. The patient was also introduced to stair climbing 2 days before his discharge. The patient was discharged after 26 days admission and 23 days of physiotherapy. At discharge, the patient’s muscle strength and functional independence were reevaluated and the outcomes are presented in Tables and, respectively. The patient could perform all activities of daily living with complete independence, except bathing/showering and stair climbing, which he did under supervision. Home programmes in line with the last phase of the intervention was given to the patient at discharge. These included free active and resistance exercises, and functional exercise (standing, squatting, and walking exercises). The patient also continued with his medical appointments and visited the physiotherapy outpatient clinic once per week for check-ups and exercises. The patient decided to stop his outpatient physiotherapy appointments afters 4 weeks (four sessions), citing that since he had gained almost total independence, there was no need to continue coming for outpatient exercise. However, he was encouraged to continue with his home programmes.