Isolated Pyridoxine Deficiency Presenting as Muscle Spasms in a Patient With Type 2 Diabetes: A Case Report and Literature Review.

Pyridoxine is an important co-factor for many biochemical reactions in cellular metabolism related to the synthesis and catabolism of amino acids, fatty acids, neurotransmitters. Deficiency of pyridoxine results in impaired transcellular signaling between neurons and presents with muscular convulsions, hyperirritability, and peripheral neuropathy. Deficiency of pyridoxine is usually found in association with other vitamin B deficiencies such as folate (vitamin B9) and cobalamin (vitamin B12). Isolated pyridoxine deficiency is extremely rare. We present the case of a 59-year old female with type 2 diabetes who complained of painful muscle spasms. Her muscle spasms involved in both feet, which have spread proximally to her legs. She also experienced intermittent muscle spasms in her left arm, which is not alleviated by baclofen, cyclobenzaprine. Her plasma pyridoxal 5-phosphate confirmed pyridoxine deficiency. Vitamins B1, B3, B12, and folate were within normal limits. The patient received standard-dose intramuscular pyridoxine injections for three weeks followed by oral supplements for 3 months and her symptoms resolved. This case illustrates the rare instance of isolated pyridoxine deficiency in type 2 diabetes patient manifesting as myoclonic muscle spasms involving the legs and arms in the absence of objective polyneuropathy. Pyridoxine level should, therefore, be assessed in patients with type 2 diabetes, including newly diagnosed patients.

Spasmodic Dysphonia.

Spasmodic dysphonia (SD) is a rare focal laryngeal dystonia. It is characterized by task-specific voice dysfluency resulting from selective intrinsic laryngeal musculature hyperfunction. Symptoms may be attenuated by a sensory trick. Although SD can be seen at times in generalized dystonia syndromes, it is typically a sporadic phenomenon. Involvement of the laryngeal adductor muscles is more common than abductor muscles. The standard treatment of this disorder is with botulinum toxin injection, usually electromyography-guided, which must be repeated periodically as the toxin wears off. A number of non-reversible surgical procedures have also been described to mitigate the symptoms. Other treatment modalities are under investigation, including implantable electrical stimulation devices and deep brain stimulation.

Acupuncture of fascia points to relieve hand spasm after stroke: a study protocol for a multicenter randomized controlled trial.

BACKGROUND: The loss of functional ability of patients after stroke is mostly caused by dysfunction of the upper limbs, especially the hands. Hand functional exercise is the premise of alleviating hand dysfunction, and the relief of hand spasm is the basis of timely and effective hand functional exercise. Previous clinical observation have shown that fascial-point needling can effectively alleviate hand spasm immediately after stroke, but further evidence from large-sample studies is needed. The overall objective of this trial is to further evaluate the clinical efficacy of fascial-point acupuncture on hand spasm after stroke. METHODS/DESIGN: This multicenter randomized controlled trial will compare the efficacy of fascial-point acupuncture versus sham acupuncture and routine rehabilitation therapy in stroke patients with hand spasm. Patients will be randomized to undergo either the fascial-point acupuncture, the sham acupuncture or the control (routine rehabilitation therapy). We will recruit 210 stroke inpatients who meet the trial criteria and observe the remission of hand spasm and improvement of limb function after 4 weeks of intervention. The first evaluation indices are the remission of hand spasm and the duration of spasm remission. The second evaluation indices are the hand function of the affected limbs and the activities of daily living. When the accumulative total number of cases included reaches 120, a mid-term analysis will be conducted to determine any evidence that experimental intervention does have an advantage. DISCUSSION: Our aim is to evaluate the efficacy of fascial-point acupuncture in relieving hand spasm after stroke. The results should provide more evidence for the clinical application of this therapy in the future. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR), ID: ChiCTR1900022379. Registered on 9 April 2019.

The Clinical Value of Assessing Lumbar Posteroanterior Segmental Stiffness: A Narrative Review of Manual and Instrumented Methods.

Abnormal spinal segmental motion/stiffness is purported to be a cause, or an effect of, low back pain. Therefore, the assessment of posteroanterior segmental spinal stiffness is a common practice in clinical and research settings. In clinical settings, manipulative practitioners routinely assess spinal stiffness manually to guide clinical decision-making. Unfortunately, the reliability of manual segmental spinal stiffness assessment is poor. As a result, various spinal stiffness-testing devices have been developed to improve the reliability and accuracy of spinal stiffness measures. Although previous critical and systematic reviews have summarized the evidence regarding the reliability and confounding factors of manual and/or instrumented spinal stiffness measurements, no available review has summarized the principles of various spinal stiffness measurement methods nor pragmatic recommendations to optimize these measurements. Importantly, although posteroanterior segmental spinal stiffness is hypothesized to be related closely to low back pain or clinical outcomes after treatments, no review has been conducted to summarize evidence related to these premises and to discuss factors that can confound these relations. Against this background, this narrative review revisits the concept of both manual and instrumented spinal stiffness assessments, summarizes the pragmatic recommendations for minimizing measurement errors, reviews the potential relations between segmental spinal stiffness and low back pain, and provides future clinical research directions that can benefit clinicians and researchers alike. LEVEL OF EVIDENCE: Not applicable.

Efficacy and safety of recombinant human parathyroid hormone (1-84) in hypoparathyroidism (REPLACE): a double-blind, placebo-controlled, randomised, phase 3 study.

BACKGROUND: Hypoparathyroidism results in impaired mineral homoeostasis, including hypocalcaemia and hyperphosphataemia. Treatment with high-dose oral calcium and active vitamin D does not provide adequate or consistent control of biochemical indices and can lead to serious long-term complications. We aimed to test the efficacy, safety, and tolerability of once-daily recombinant human parathyroid hormone 1-84 (rhPTH[1-84]) in adults with hypoparathyroidism. METHODS: In this double-blind, placebo-controlled, randomised phase 3 study (REPLACE), we recruited patients with hypoparathyroidism (≥ 18 months duration) aged 18-85 years from 33 sites in eight countries. After an optimisation period, during which calcium and active vitamin D doses were adjusted to achieve consistent albumin-corrected serum calcium, patients were randomly assigned (2:1) via an interactive voice response system to 50 µg per day of rhPTH(1-84) or placebo for 24 weeks. Active vitamin D and calcium were progressively reduced, while rhPTH(1-84) could be titrated up from 50 µg to 75 µg and then 100 µg (weeks 0-5). The primary endpoint was the proportion of patients at week 24 who achieved a 50% or greater reduction from baseline in their daily dose of oral calcium and active vitamin D while maintaining a serum calcium concentration greater than or the same as baseline concentrations and less than or equal to the upper limit of normal, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00732615. FINDINGS: Between June 23, 2009, and Feb 28, 2011, 134 eligible patients were recruited and randomly assigned to rhPTH(1-84) (n=90) or placebo (n=44). Six patients in the rhPTH(1-84) group and seven in the placebo group discontinued before study end. 48 (53%) patients in the rhPTH(1-84) group achieved the primary endpoint compared with one (2%) patient in the placebo group (percentage difference 51.1%, 95% CI 39.9-62.3; p<0.0001). The proportions of patients who had at least one adverse event were similar between groups (84 [93%] patients in the rhPTH[1-84] group vs 44 [100%] patients in the placebo group), with hypocalcaemia, muscle spasm, paraesthesias, headache, and nausea being the most common adverse events. The proportions of patients with serious adverse events were also similar between the rhPTH(1-84) group (ten [11%] patients) and the placebo group (four [9%] patients). INTERPRETATION: 50 µg, 75 µg, or 100 µg per day of rhPTH(1-84), administered subcutaneously in the outpatient setting, is efficacious and well tolerated as a PTH replacement therapy for patients with hypoparathyroidism.

Psoas syndrome: a frequently missed diagnosis.

Psoas syndrome is an easily missed diagnosis. However, it is important to consider this condition as part of the differential diagnosis for patients presenting with low back pain--particularly for osteopathic physicians, because patients may view these practitioners as experts in musculoskeletal conditions. The authors describe the case of a 48-year-old man with a 6-month history of low back pain that had been attributed to "weak core muscles." The diagnosis of psoas syndrome was initially overlooked in this patient. After the correct diagnosis was made, he was treated by an osteopathic physician using osteopathic manipulative treatment, in conjunction with at-home stretches between office treatments. At his 1-month follow-up appointment, he demonstrated continued improvement of symptoms and a desire for further osteopathic manipulative treatment.

Muscle spasm associated with therapeutic use of Cang Er Zi Wan.

INTRODUCTION: Cang Er Zi Wan (CEZW) is a herbal medication derived from Xanthium sibiricum that is used to treat allergies and upper respiratory problems. Its toxicity has been described in grazing animals, in experimental studies, and in human overdoses. We describe a case of muscular spasm that was associated with the therapeutic use of CEZW. CASE REPORT: A 17-year-old female was prescribed CEZW for chronic allergies. Shortly after her second dose of 10 pills BID, she developed intermittent muscular spasms. She was seen in an Emergency Department and had normal vital signs and no significant laboratory abnormalities. Her physical exam was significant only for intermittent spasm of the muscles of the face, neck, and upper extremities. No tremor, fasciculation, dystonia, akisthisia, chorea, bradykinesia, or clonus was noted. She discontinued the CEZW and the symptoms slowly decreased over 4 days. Testing of the product did not detect any other medications or drugs. DISCUSSION: CEZW is a herbal medication that contains X. sibiricum. X. sibiricum is a widespread weed that has caused muscular spasm, seizures, and death in animals that graze on it as well as animals experimentally exposed to it. Eleven cases of accidental human ingestion of Xanthium leading to spasm, somnolence, hypoglycemia, renal, and liver toxicity have been described. We describe a unique case of isolated muscular spasms because of the therapeutic use of a CEZW product.

Chronic prostatitis/chronic pelvic pain syndrome and pelvic floor spasm: can we diagnose and treat?

National Institutes of Health category III prostatitis, also known as chronic prostatitis/chronic pelvic pain syndrome, is a common condition with significant impact on quality of life. This clinically defined syndrome has a multifactorial etiology and seems to respond best to multimodal therapy. At least half of these patients have pelvic floor spasm. There are several approaches to therapy including biofeedback, acupuncture, and myofascial release physical therapy. However, the only multicenter study of pelvic floor physical therapy for pelvic floor spasm in men failed to show an advantage over conventional Western massage. We have proposed a clinical phenotyping system called UPOINT to classify patients with urologic chronic pelvic pain and subsequently direct appropriate therapy. Here, we review the current approach to category III prostatitis and describe how clinical phenotyping with UPOINT may improve therapy outcomes.

Evaluation of the levator ani and pelvic wall muscles in levator ani syndrome.

Chronic pelvic pain is a difficult problem to evaluate and treat. Knowledge of the pelvic floor and pelvic wall muscles may enable the provider to identify levator ani spasm syndrome, a possible cause of chronic pelvic pain.

[Diagnosis and treatment of post traumatic spasmodic flat foot].

OBJECTIVE: To discuss diagnosis and treatment of post traumatic spasmodic flat foot. METHODS: From 2002 to 2007, 7 diagnosed patients were recruited and underwent following procedures: under epidural anesthesia or common peroneal nerve block anesthesia, massage was performed on the peroneal muscles for about 5 minutes, then ankle joint was underwent with passive functional exercise. Feeling muscle relaxation, we held the wounded foot in varus and adducted position forcefully, then immobilized it with short leg cast. After 3 weeks of continuous immobilization, the cast was removed and patients were given physical treatment and functional training. RESULTS: Symptoms of these patients such as claudication and pain in foot were improved, the foot deformity was corrected and foot arch restored to normal. After a follow-up of 6 months,no obvious recurrence was observed. CONCLUSION: The diagnosis of post traumatic spasmodic flat foot is based on the careful inquiry of traumatic history,physical examination and X-ray results. Manipulative reduction under common peroneal nerve block anesthesia and cast immobilization is a simple and effective method to treat this disease.

Levator ani trigger point injections: An underutilized treatment for chronic pelvic pain.

AIMS: We conducted this study to examine the role of trigger point injections in females with chronic pelvic pain (CPP) of at least 6 months duration and specific levator ani trigger points. METHODS: This prospective study included 18 consecutive female patients with CPP and specific palpable levator ani trigger points. Pain was evaluated before and after trigger point injection on a Visual Analog Scale (VAS). Patient global satisfaction (PGS) and cure rates (PGC) were also measured by a VAS on a scale of 0-100%. The trigger points were identified manually by intravaginal palpation of the levator ani bilaterally. A mixture of 10 cc of 0.25% bupivacaine, 10 cc of 2% lidocaine and 1 cc (40 mg) of triamcinolone was used for injection of 5 cc per trigger point. A 5.5'' Iowa trumpet pudendal needle guide was used for injection. All but one injection were performed in the office setting without sedation. Pelvic floor muscle exercises were taught for use after injection. Success was defined as a decrease in pain as measured by a VAS of 50% or more, as well as PGS and PGC scores of 60% or greater. There was a mean follow up of 3 months after trigger point injection. RESULTS: Thirteen of 18 women improved with the first trigger point injection resulting in a comprehensive success rate of 72%. Six (33%) of 18 women were completely pain free. CONCLUSION: In the management of CPP, a non-surgical office-based therapy such as trigger point injections can be effective in selected patients.

Use of botulinum toxin type A on orthopedics: a case report.

Botulinum toxin type A is effective in treating neurologic entities with increased muscle tone. Few reports show the benefits of this treatment for orthopedic conditions. We present the case of a 54-year-old man who manifested bilateral pectoralis major stiffness and bilateral shoulder pain; he had a score of 6 on a visual analog scale (VAS). Complex regional pain syndrome (type I) after cardiac surgery, which had already been resolved, was significant in the patient's clinical background. On examination, neither increases in muscle tone nor signs of tendinous or joint pathology was found. However, the patient experienced significant pain when both pectorals were stretched. The patient's Constant score, a validated scale of shoulder function, was 45/100 on the right shoulder and 41/100 on the left. The patient's shoulder stiffness and pain neither responded to rehabilitation (stretching exercises, passive mobilization, electrostimulation) nor to oral medication (alprazolam, gabapentin). Despite the lack of increased muscle tone, we decided to administer botulinum toxin type A to control pain. Subsequently, pain intensity was reduced to 4 on a VAS on both sides, and functionality improved (Constant scale score, 62 on the right side; 60 on the left). This improvement enabled the patient to resume his job as a building supervisor, which required active involvement in physical construction work.

Nipple vasospasms, Raynaud's syndrome, and nifedipine.

This case report describes a situation in which a mother who experienced prolonged nipple pain with her first child sought help from a lactation consultant at the birth of her second child. Despite being very attentive to positioning and latch, similar pain was experienced from the first feeding with the second baby. The mother's history and symptoms were explored, and nipple vasospasms related to Raynaud's syndrome were suspected. After reviewing the literature and consulting with her personal obstetrician, the mother (a pediatrician) chose to treat with nifedipine. The mother was pain free after a 2-week course and nursing without difficulty at 4 months postpartum.

Improvement of severe trunk spasms by bilateral high-frequency stimulation of the motor thalamus in a patient with chorea-acanthocytosis.

We report on a patient with a severe form of chorea-acanthocytosis, intractable to medical treatment, who benefited from bilateral high-frequency stimulation (HFS) of the posterior ventral oral nucleus of the thalamus. The frequency of trunk spasms dramatically decreased after surgery and the clinical benefit remained stable 1 year later. However, no clear effect was observed on dysarthria nor on hypotonia, which always impaired gait. We propose that HFS of the motor thalamus is a potential treatment for choreic or truncal dystonic symptoms whenever hypotonia is not the main feature of the syndrome.

Influence of standardized mobilization on the posteroanterior stiffness of the lumbar spine in asymptomatic subjects.

BACKGROUND AND PURPOSE: Spinal mobilization is commonly used to relieve pain and assist recovery of mobility in individuals with low back pain. Fundamental to this concept is the belief that spinal mobilization will influence the mechanical properties of the symptomatic motion segment. The objective of the present study was to examine the segmental effects of a standardized mobilization procedure on the posteroanterior (PA) stiffness of the lumbar spine. METHOD: Audio and visual feedback was used to train a physiotherapist to perform PA mobilization at a consistent load and frequency. After training, twenty-four subjects without low back pain were recruited for the intervention phase of the study. The spinal posteroanterior mobilization (SPAM) apparatus was used to measure the PA stiffness of the lumbar spine at three measurement sites (L1, L3 and L5). The trained physiotherapist then applied the standardized PA mobilization technique via the L3 spinous process for two minutes. Following mobilization, PA stiffness was measured three times at the three locations. RESULTS: The physiotherapist was able to apply a standardized mobilization with a mean force of 146 N (standard deviation (SD) 8 N) at a frequency of 1.5 Hz. The first trial on each assessment demonstrated a pre-condition effect. Two minutes' PA mobilization resulted in no significant change in the PA stiffness of the lumbar spine at the level to which the mobilization was applied, or at the L1 and L5 segments. The 95% confidence intervals (CI) of the difference in PA stiffness before and after testing included zero at each measurement site. CONCLUSIONS: Clinicians should pre-condition the spine when assessing PA stiffness both before and after interventions. A standardized mobilization of 150 N at 1.5 Hz for two minutes had no segmental effect on spinal PA stiffness. Subsequent studies need to consider other mechanisms that may contribute to the changes that occur after PA spinal mobilization.

Muscle tension dysphonia and spasmodic dysphonia: the role of manual laryngeal tension reduction in diagnosis and management.

Excessive activity of the extralaryngeal muscles affects laryngeal function and contributes to a spectrum of interrelated symptoms and syndromes including muscle tension dysphonia and spasmodic dysphonia. Recognition of the role of extralaryngeal tension is helpful in ensuring proper diagnosis and selection of appropriate treatment. This report demonstrates the application of manual laryngeal musculoskeletal tension reduction techniques in the diagnosis and management of laryngeal hyperfunction syndromes. The manual technique consists of focal palpation to determine 1) extent of laryngeal elevation, 2) focal tenderness, 3) voice effect of applying downward pressure over the superior border of the thyroid lamina, and 4) extent of sustained voice improvement following circum-laryngeal massage. The clinical utility of this innovative approach is discussed.

[The treatment of vasospastic disease by chronic spinal cord stimulation. A case report]. / Tratamiento de la enfermedad vasoespática con la estimulación medular crónica. Presentación de un caso.

In 1976, by first time, Cook used the chronic medullar stimulation (CMS) for the treatment of chronic arteriopathies at the limbs in patients with distal ischemic ulcerations. Up to now, some studies about this procedure have been published. Results, poor at first, have presented an important improvement with the time and the better choosing of patients. In 1981, Neglio used by first time CMS as a treatment of vasospastic disease, with excellent results. With this procedure, pain and vasospastic crisis disappeared and re-epithelialization of ischemic ulcerations is found. In this article, we presented a case interesting because it show the different possibilities of this method as a symptomatic treatment of such kind of disease. Patient, with a Raynaud syndrome secondary to an sclerodermia treated previously by medical and surgical procedures, was treated, in different times, with CMS because of digital ischemic ulcerations in both hands. Results were positives and ulcerations healed.

[Treatment of patients with facial hemispasm by transcutaneous electric nerve stimulation]. / Lechenie bol'nykh litsevym gemispazmom metodom cheskozhnoi élektroneirostimuliatsii.

Fifty-two patients (aged 15 to 78 years) suffering from facial hemispasm were treated by transcutaneous electric nerve stimulation (TENS). For this purpose electric-impulse apparatuses generating bipolar nonsymmetrical impulses were employed. The employment of TENS eliminated hyperkinesis for a period of several minutes to several hours. Interparoxysmal intervals lengthened and hyperkinesis became less pronounced. After a TENS session EMG showed no spontaneous activity in the form of "volleys of oscillations". A possible mechanism of TENS therapeutic effect in facial hemispasm is discussed.

The levator syndrome and its variant.

The levator syndrome is an entity characterized by pain high in the rectal area that can be elicited by pressure applied to the levator ani. The etiology, diagnosis, and treatment of this disorder are described. Its importance lies in its misdiagnosis or in the failure to diagnose.