Passive accessory joint mobilization in the multimodal management of chronic dysesthesia following thalamic stroke.

Study design: Case Report. Purpose: Stroke is the most common cause of long-term disability. Dysesthesia, an unpleasant sensory disturbance, is common following thalamic stroke and evidence-based interventions for this impairment are limited. The purpose of this case report was to describe a decrease in dysesthesia following manual therapy intervention in a patient with history of right lacunar thalamic stroke. Case description: A 66-year-old female presented with tingling and dysesthesia in left hemisensory distribution including left trunk and upper/lower extremities, limiting function. Decreased left shoulder active range of motion, positive sensory symptoms but no sensory loss in light touch was found. She denied pain and moderate shoulder muscular weakness was demonstrated. Laterality testing revealed right/left limb discrimination deficits and neglect-like symptoms were reported. Passive accessory joint motion assessment of glenohumeral and thoracic spine revealed hypomobility and provoked dysesthesia. Interventions included passive oscillatory joint mobilization of glenohumeral joint, thoracic spine, ribs and shoulder strengthening. Results: After six sessions, shoulder function, active range of motion, strength improved and dysesthesia decreased. Global Rating of Change Scale was +5 and QuickDASH score decreased from 45% to 22% disability. Laterality testing was unchanged. Conclusion: Manual therapy may be a beneficial intervention in management of thalamic stroke-related dysesthesia. Implications for Rehabilitation While pain is common following thalamic stroke, patients may present with chronic paresthesia or dysesthesia, often in a hemisensory distribution. Passive movement may promote inhibition of hyperexcitable cortical pathways, which may diminish aberrant sensations. Passive oscillatory manual therapy may be an effective way to treat sensory disturbances such as paresthesias or dysesthesia.

[Personal response to disease at paresthesia oral mucosa].

A study related to the disease in 39 (7 men and 32 women) people aged 61-86 years, suffering from paresthesia oral mucous membranes (POMM). To determine the type of relationship to the patient's illness was used clinical test method which employs a clinical-psychological typology of relationship to the patient's illness. It was found that for patients with middle and old age (69,2 %), suffering from severe and moderate POMM severity of pathology characteristic intrapsychic focus of personal response to the disease, is caused due to the presence of a constant burning sensation in the mouth, often accompanied by the syndrome of «dry mouth¼ violation of social adaptation of patients. For the older age groups suffering POMM, which proceeded in a light, at least moderate disease severity (28,2 %) is characteristic orientation interpsychic personal response to the disease, also causes disturbances of social adaptation of patients. The obtained information about the type of relationship the patients of elderly and senile age, suffering POMM show that to achieve a positive therapeutic outcome and successful rehabilitation is necessary to change their existing inadequate response to disease, it is possible by attracting clinical pharmacologist and (or) the therapist.

Tratamento de fratura de assoalho orbital com cartilagem conchal / Treatment of orbital floor fracture with conchal cartilage

Introdução: A reconstrução dos defeitos no assoalho orbital após fraturas constitui um desafio ao cirurgião plástico, pois além da expectativa estética e reconstrutora do paciente, cabe o tratamento de possíveis complicações funcionais, como diplopia e parestesias faciais. O objetivo é demonstrar uma série de casos utilizando cartilagem auricular conchal para reposição volumétrica orbital e estrutural do assoalho. Métodos: Foram avaliados 24 pacientes, operados pelo autor deste trabalho no período de 2013 a 2016, por motivo de fraturas de assoalho orbital pura (blow-out) ou impura (conjugadas a lesões de margem orbital, como zigoma e maxila). A técnica de estruturação do assoalho utilizou enxerto cartilaginoso autólogo conchal em todos os casos. Os pacientes foram catalogados quanto à presença de queixas pré-operatórias, como parestesia e diplopia, e sintomas, como enoftalmia, assim como resultados pós-operatórios. Resultados: A presença de lesões concomitantes como fratura de complexo zigomático e fratura maxilar pode influenciar no sucesso da reconstrução, assim como as fraturas com maior área de descontinuidade no assoalho orbital. Poucos pacientes apresentaram queixas pós-operatórias e somente dois casos (9,2%) necessitaram de nova abordagem cirúrgica. Conclusão: A cartilagem conchal auricular autóloga é um material adequado à reconstrução de defeitos no assoalho orbital pós-fratura, apresentando como vantagens a fácil obtenção, baixa morbidade, cicatriz inconspícua, excelente adaptação ao formato do assoalho da órbita e consequente reposição volumétrica.

Introduction: The reconstruction of defects in the orbital floor after fractures poses a challenge to the plastic surgeon because besides the patient's aesthetic and reconstructive expectations, possible functional complications such as diplopia and facial paresthesia must be treated. This study aimed at reporting a series of cases in which conchal auricular cartilage was used for volumetric orbital and structural replacement of the floor. Methods: Twenty-four patients, with surgery performed by the author, between 2013 and 2016, for pure (blow-out) or impure (conjugated to orbital margin injuries, such as zygoma and maxilla) orbital floor fractures, were evaluated. The repair technique involved autologous conchal cartilage graft in all cases. Patients were classified for the presence of preoperative complaints, including paresthesia and diplopia, and symptoms such as enophthalmia, as well as postoperative outcomes. Results: The existence of concomitant lesions, such as zygomatic complex and maxillary fracture, as well as fractures with greater discontinuity in the orbital floor, may influence the success of reconstruction. Few patients exhibited postoperative complaints and only two (9.2%) required a new surgical approach. Conclusion: Autologous conchal auricular cartilage is a suitable material for reconstruction of defects in the post-fracture orbital floor, possessing various advantages, including ease of attainment, low morbidity, inconspicuous scar, and excellent adaptation to the shape of the orbital floor and consequent volumetric replacement.

Somatic tinnitus prevalence and treatment with tinnitus retraining therapy.

OBJECTIVES: Somatic tinnitus originates from increased activity of the dorsal cochlear nucleus, a cross-point between the somatic and auditory systems. Its activity can be modified by auditory stimulation or somatic system manipulation. Thus, sound enrichment and white noise stimulation might decrease tinnitus and associated somatic symptoms. The present uncontrolled study sought to determine somatic tinnitus prevalence among tinnitus sufferers, and to investigate whether sound therapy with counselling (tinnitus retraining therapy; TRT) may decrease tinnitus-associated somatic symptoms. METHODS: To determine somatic tinnitus prevalence, 70 patients following the TRT protocol completed the Jastreboff Structured Interview (JSI) with additional questions regarding the presence and type of somatic symptoms. Among 21 somatic tinnitus patients, we further investigated the effects of TRT on tinnitus-associated facial dysesthesia. Before and after three months of TRT, tinnitus severity was evaluated using the Tinnitus Handicap Inventory (THI), and facial dysesthesia was assessed with an extended JSI-based questionnaire. RESULTS: Among the evaluated tinnitus patients, 56% presented somatic tinnitus-including 51% with facial dysesthesia, 36% who could modulate tinnitus by head and neck movements, and 13% with both conditions. Self-evaluation indicated that TRT significantly improved tinnitus and facial dysesthesia in 76% of patients. Three months of TRT led to a 50% decrease in mean THI and JSI scores regarding facial dysesthesia. CONCLUSIONS: Somatic tinnitus is a frequent and underestimated condition. We suggest an extension of the JSI, including specific questions regarding somatic tinnitus. TRT significantly improved tinnitus and accompanying facial dysesthesia, and could be a useful somatic tinnitus treatment.

Comparison between Steroid Injection and Stretching Exercise on the Scalene of Patients with Upper Extremity Paresthesia: Randomized Cross-Over Study.

PURPOSE: To compare the therapeutic effects on upper extremity paresthesia of intra-muscular steroid injections into the scalene muscle with those of stretching exercise only. MATERIALS AND METHODS: Twenty patients with upper extremity paresthesia who met the criteria were recruited to participate in this single-blind, crossover study. Fourteen of 20 patients were female. The average age was 45.0 ± 10.5 years and duration of symptom was 12.2 ± 8.7 months. Each participant completed one injection and daily exercise program for 2 weeks. After randomization, half of all patients received ultrasound-guided injection of scalene muscles before exercise, while the other was invested for the other patients. RESULTS: After two weeks, there was a significant decrease of the visual analog scale score of treatment effect compared with baseline in both groups (6.90 to 2.85 after injection and 5.65 to 4.05 after stretching exercise, p<0.01). However, injection resulted in greater improvements than stretching exercise (p<0.01). The number of patients with successful treatment, defined as >50% reduction in post-treatment visual analog scale, was 18 of 20 (90.0%) after injection, compared to 5 of 20 (25.0%) after stretching exercise. There were no cases of unintended brachial plexus block after injection. CONCLUSION: Ultrasound-guided steroid injection or stretching exercise of scalene muscles led to reduced upper extremity paresthesia in patients who present with localized tenderness in the scalene muscle without electrodiagnostic test abnormalities, although injection treatment resulted in more improvements. The results suggest that symptoms relief might result from injection into the muscle alone not related to blockade of the brachial plexus.

Notalgia paraesthetica: A pilot study of treatment with simple exercises and stretches.

Notalgia paraesthetica is a distressing condition for which current treatments are either poorly effective or have unacceptable adverse effects. The aim of this pilot study was to evaluate the effectiveness of a programme of simple exercises and stretches for this condition. In total, 12 patients participated in a trial of simple exercises and stretches over 12 weeks, designed to relieve the sensory neuropathy caused by paraspinal muscle entrapment. Of the 12 patients 11 achieved satisfactory amelioration of their symptoms with no adverse effects. Our pilot study was unblinded and consisted of small patient numbers. Further research to evaluate this approach is warranted.

NTOS symptoms and mobility: a case study on neurogenic thoracic outlet syndrome involving massage therapy.

Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain, muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility.

[Acute intermittent porphyria: a diagnostic dilemma]. / La porfiria aguda intermitente, un problema diagnóstico.

Acute intermittent porphyria (AIP) is a rare condition characterized by abdominal pain and a wide range of nonspecific symptoms. We report the case of a 24-year-old woman with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and motor and sensory neurological deficits due to an attack of acute porphyria. The patient presented to the emergency department with abdominal pain. The results of physical examination and laboratory investigations were normal. Two days after admission, the patient developed seizures as a result of hyponatremia due to SIADH, which, together with the observation of red urine, led to the diagnosis of AIP. Before hematin was available, the patient developed autonomic instability and peripheral neuropathy with muscular weakness. We briefly review the clinical and laboratory features of this syndrome and emphasize the importance of its inclusion in the differential diagnosis of gastrointestinal diseases, hyponatremia and neuropathy. Prompt recognition of this entity and early specific treatment with haem arginate are important to prevent irreversible complications.

Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: a randomised, placebo-controlled trial.

Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome. To date no controlled studies have investigated the effects of thoracic spinal manual therapy (SMT) applied to T4 on sympathetic activity in the hands. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of 0.5 Hz had demonstrably greater effects than a validated placebo intervention on skin conductance (SC) in the hands of healthy subjects. A power analysis calculation was performed and using a double blind, placebo-controlled, independent groups design, 36 healthy subjects (18-35 years) were randomly assigned to two groups (placebo intervention or treatment intervention). A BioPac unit recorded continuous SC measures before, during and after each experimental intervention. An exit questionnaire was used to validate the expectancy effects of the placebo intervention. Results demonstrated a significant difference between groups in SC in the right hand during the post-treatment rest period (F = 4.888, p = 0.034); with the treatment intervention being sympathoexcitatory in nature. A trend towards a significant difference between groups was also demonstrated in the left hand during the rest period (F = 4.072, p = 0.052). This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the hand. Further research is recommended in a patient population.

Meralgia paresthetica secondary to limb length discrepancy: case report.

Meralgia paresthetica consists of pain and dysthesia in the lateral thigh caused by entrapment of the lateral femoral cutaneous nerve (L2-L3) underneath the inguinal ligament. Abdominal distension, tight clothing, and hip hyperextension are all described causes of this condition. To our knowledge this has never been attributed to a limb length discrepancy. We present a 51-year-old man with a long-standing history of right sided meralgia paresthetica. History and physical and radiological examination were unrewarding except that his left leg was shorter than the right by 2 cm. Nerve conduction studies of the lateral femoral cutaneous nerve on the left had a normal latency and amplitude but were absent on the right. To prove the hpothesis that the limb length discrepancy was responsible for the condition, a single subject study was performed. The presence or absence of pain and dysesthesia in the right thigh was the observed behavior. Intervention consisted of wearing a 1.5-cm lift in the left or right shoe for 2 weeks each with an intervening 2-week lift-free period. Pain was recorded on a numeric scale and numbness as being present or absent. There was continuing pain without and with the lift in the right shoe but no pain or numbness with the lift in left shoe. It was concluded that the limb length discrepancy was responsible for the meralgia paresthetica. Pertinent literature and possible pathomechanics are discussed.

Industrial rehabilitation medicine. 3. Case studies in upper extremity cumulative trauma disorders.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section contains three case studies discussing nerve, joint, and soft tissue pathology and work disability due to upper extremity pain. New areas of interest covered in this section include the controversy regarding the work causality of upper extremity disorders, a detailed review of the impact of upper quadrant postural dysfunction on symptom perpetuation, and the assessment and nonsurgical management of thoracic outlet syndrome.

[After care and rehabilitation following surgery of peripheral nerves]. / Nachbehandlung und Rehabilitation nach Operationen an peripheren Nerven.

In cases with direct nerve repair we consider a plaster cast immobilization of three weeks as adequate; for those with nerve grafts, two weeks are sufficient. In the later course, the patient should regularly be examined also for Tinel's sign, to make sure that this progresses distally corresponding to normal nerve regeneration. If after four to five months the Tinel's sign has not progressed distally, the regenerating nerve fibres are most likely to be blocked by scar tissue formation, and revisional surgery may be indicated. As in all surgery of the hand, the role of a postoperative hand therapy program is of critical importance. In many cases specific sensory reeducation may definitely contribute to improve the final functional result after restoration of peripheral nerves.

[Rehabilitation after lumbar intervertebral disk operation]. / Rehabilitation nach lumbaler Diskusoperation.

122 patients were admitted 3 months after a lumbar disc operation to a rehabilitation clinic. Conservative treatment during the rehabilitation induced a decrease of low back pain (70 out of 107 patients), of paresis (30/51 patients), and of paresthesia (51/77 patients). More than 20 pre- and post-operative variables were tested with a rank-variance analysis regarding a possible influence on efficacy of the rehabilitation treatment. The success of the conservative treatment measured by improvement of paresis, paresthesia, pain and mobility of lumbar spine was influenced favourably by preoperative paresis (p less than 0.03). Women showed more often than men an improvement of paresis (p = 0.006) immediately after surgery. Patients with a preoperative paresis had a shorter history of radicular symptoms (p = 0.002), an acute onset was seen more often in patients with persistent paresis (p = 0.019). Paresthesia was found more frequently before surgery (p = 0.010) and at begin of rehabilitation (p = 0.006) in patients with paresis compared to patients without paresis. A statistically significant association was also evaluated between decreased lumbar mobility and laminectomy (p = 0.007). Patients with L5/S1 disc operation had a longer duration of radicular symptoms (p = 0.012), a decreased frequency of paresis (p = 0.040), but more often paresthesia (p = 0.001) compared with L4/5 operation.

Successful reeducation of functional sensibility after median nerve repair at the wrist.

The effect of sensory reeducation was evaluated in a group of twenty-two adult patients who had a repair of a clean-cut median nerve at the wrist. These results were compared with the sensibility in a group of twenty-four adults with repair of clean-cut median nerve at the wrist who had never received sensory reeducation. The reeducation group were evaluated between one and two years from the time of their median nerve repair. The control patients were retrospectively evaluated between one and sixteen years after their nerve repair. The effect of reeducation on improving the paresthesias that accompany neural regeneration was also evaluated. Sensibility was determined by an object recognition test and by measurement of static and moving two-point discrimination. The results demonstrated that sensory reeducation significantly (p less than 0.01) diminished the severity of postoperative paresthesias. It also gave significantly better improvement in moving two-point discrimination than in static two-point discrimination within the timeframe evaluated (p less than 0.002). Excellent recovery of sensibility, as determined by ability to recognize nine or more objects out of twelve, was significantly greater (p less than 0.005) for the sensory reeducation group than at any time interval beginning after six months after nerve repair. It is concluded that a program of sensory reeducation after median nerve repair at the wrist in adults minimizes discomfort and improves sensibility in the postoperative period.

[Course and prognosis of the rehabilitation of patients following acute polyneuritis]. / Verlauf und Prognose der Rehabilitation von Patienten nach akuter Polyneuritis.

Presented are 31 patients who had been admitted to our clinic for physical medicine for post-acute rehabilitation treatment. On admission, 25 of them suffered from incomplete tetraparesis. All patients were able to walk at discharge, some still having to rely on aids. 29 patients had achieved full independence in ADL tasks. Further gains in muscular strength and functional capacity were achieved over a period of up to two years of continued treatment on an outpatient basis.

Bilateral microneurosurgical reconstruction of inferior alveolar nerves via autogenous sural nerve transplantation.

Microneurosurgical operative techniques permit satisfactory restoration of sensation in many lesions of the inferior alveolar nerve. Therefore, restoration of the sensory deficit is becoming increasingly more important in the total functional rehabilitation of individuals with mandibular continuity defects involving transection of or permanent damage to the inferior alveolar nerve. This article reviews the case history of a young man who underwent bilateral osseous mandibular reconstruction and microneurosurgical reconstruction of his inferior alveolar nerves following severe maxillofacial trauma. A new technique for isolating the sural nerve is introduced to facilitate harvesting of the graft. Scanning electron microscopic examination of the resected proximal inferior alveolar nerve is recommended to determine the prognosis for regeneration across the proximal anastomosis and to decide whether secondary resection and reanastomosis of the distal anastomosis is indicated when anesthesia persists 9 to 12 months after initial transplantation of a long donor nerve.