A CARE-compliant article: a case report of idiopathic brachial neuritis treated with ultrasound-guided electroacupuncture.

RATIONALE: Electroacupuncture is commonly used for treating nerve injury. However, studies published in recent years have not described an appropriate method for accurately identifying the location and depth of injured nerves beneath the acupoints. PATIENT CONCERNS: A 26-year-old male patient had left shoulder pain and weakness after tetanus, diphtheria, and pertussis vaccination and was diagnosed with idiopathic brachial neuritis 24 months before this study. The patient had undergone prednisone and ibuprofen treatment in another hospital, but the therapeutic effect was poor and limited. DIAGNOSES: The nerve conduction studies showed decreased amplitude over the left supraspinatus and deltoid muscles. Electromyography showed increased giant waves and polyphasic waves with reduced recruitments in the left deltoid muscle and increased giant waves with reduced recruitment in the left supraspinatus muscle. The condition was diagnosed with idiopathic brachial neuritis. INTERVENTIONS: Ultrasound was used to identify the location and depth of axillary and suprascapular nerves, and direct electroacupuncture was conducted at the quadrangular space and suprascapular notch to stimulate the nerves. Other needles were placed according to deltoid and supraspinatus muscles origins and insertions. The procedure was conducted once a week, and rehabilitation activities were conducted daily. OUTCOMES: The patient experienced significant improvements of left shoulder pain and muscle weakness after ultrasound-guided electroacupuncture treatment. The total shoulder pain and disability index score declined from 49.23% to 11.54%. The scores of both pain and disability domains improved and maintained stable declining after the intervention. The disability of the arm, shoulder; and hand scores declined from 60 to 23.3. According to amplitude data from nerve conduction studies, the injured axillary nerve showed remarkable improvement in the third month. Muscle strength improved to the normal state. The patient was generally satisfied with the ultrasound-guided electroacupuncture treatment. LESSON: Ultrasound-guided electroacupuncture was based on anatomical correlations between nerves and muscles and on electrical stimulation theories. The results suggest that this intervention might be an alternative therapy for idiopathic brachial neuritis. Furthermore, in this study, it had minimal adverse effects. This therapy is demonstrated to be effective in future controlled studies.

Idiopathic neuralgic amyotrophy: an illustrative case report.

OBJECTIVE: To describe the case of a patient diagnosed with neuralgic amyotrophy (NA) illustrating pertinent aspects of differential diagnosis, the use of clinical neurophysiological procedures to aid in establishing the diagnosis, and issues of management. CLINICAL FEATURES: A 39-year-old male soldier presented with a rapid onset of marked loss of left shoulder movement. This started acutely early one morning as a sharp, severe lower neck pain progressing over the following 2 weeks to a less severe dull ache in the left shoulder and arm. Pain was rapidly replaced with weakness. Physical examination and electrodiagnostic investigation helped establish a diagnosis of NA. INTERVENTION AND OUTCOME: The patient was reassured that this is normally a self-limiting condition. Range of motion exercises progressing to a strengthening program was prescribed. He was progressing well; however, we lost contact because of his commitments in the armed service. CONCLUSION: When a patient presents with shoulder and arm pain of neurogenic origin, NA should be a consideration. Differentiating NA from radiculopathy is especially important in making management decisions. With a careful history and physical examination, the diagnosis may be made without the need for ancillary investigations. Neuralgic amyotrophy is a self-limiting condition requiring reassurance and monitoring.

Neurogenic pain relief by repetitive transcranial magnetic cortical stimulation depends on the origin and the site of pain.

OBJECTIVE: Drug resistant neurogenic pain can be relieved by repetitive transcranial magnetic stimulation (rTMS) of the motor cortex. This study was designed to assess the influence of pain origin, pain site, and sensory loss on rTMS efficacy. PATIENTS AND METHODS: Sixty right handed patients were included, suffering from intractable pain secondary to one of the following types of lesion: thalamic stroke, brainstem stroke, spinal cord lesion, brachial plexus lesion, or trigeminal nerve lesion. The pain predominated unilaterally in the face, the upper limb, or the lower limb. The thermal sensory thresholds were measured within the painful zone and were found to be highly or moderately elevated. Finally, the pain level was scored on a visual analogue scale before and after a 20 minute session of "real" or "sham" 10 Hz rTMS over the side of the motor cortex corresponding to the hand on the painful side, even if the pain was not experienced in the hand itself. RESULTS: and discussion: The percentage pain reduction was significantly greater following real than sham rTMS (-22.9% v -7.8%, p = 0.0002), confirming that motor cortex rTMS was able to induce antalgic effects. These effects were significantly influenced by the origin and the site of pain. For pain origin, results were worse in patients with brainstem stroke, whatever the site of pain. This was consistent with a descending modulation within the brainstem, triggered by the motor corticothalamic output. For pain site, better results were obtained for facial pain, although stimulation was targeted on the hand cortical area. Thus, in contrast to implanted stimulation, the target for rTMS procedure in pain control may not be the area corresponding to the painful zone but an adjacent one. Across representation plasticity of cortical areas resulting from deafferentation could explain this discrepancy. Finally, the degree of sensory loss did not interfere with pain origin or pain site regarding rTMS effects. CONCLUSION: Motor cortex rTMS was found to result in a significant but transient relief of chronic pain, influenced by pain origin and pain site. These parameters should be taken into account in any further study of rTMS application in chronic pain control.

Effectiveness of manipulative physiotherapy for the treatment of a neurogenic cervicobrachial pain syndrome: a single case study -- experimental design.

A single case study ABC design was used to evaluate the effectiveness of manipulative physiotherapy in a 44-year-old woman with an 8-month history of neurogenic cervicobrachial pain. Clinical examination demonstrated significant signs of upper quadrant neural tissue mechanosensitivity indicating that neural tissue was the dominant tissue of origin for the subject's complaint of pain. Magnetic resonance imaging revealed correlating discal pathology at the C5/6 intersegmental level. The study involved a 4-week pre-assessment phase, a 4-week treatment phase and a 2-week home exercise phase. Functional disability was measured using the Northwick Park Neck Pain Questionnaire and pain was assessed using the McGill Short Form Pain Questionnaire. Cervical motion was measured by a cervical range of motion device (CROM) and the range of shoulder abduction with a mediclino inclinometer. Manipulative physiotherapy treatment involved a cervical lateral glide mobilization technique. Following treatment, visual analysis revealed beneficial effects on pain, functional disability as well as cervical and shoulder mobility. These improvements were maintained over the home exercise phase and at 1-month follow-up. The single case limits generalization of the findings, but the results support previous studies in this area and gives further impetus to controlled clinical trials.

Case reports: headache caused by a spinal cord stimulator in the upper cervical spine.

We report persistent headaches developing in a patient subsequent to the placement of a spinal cord stimulator in the upper cervical spine. These persistent headaches responded to dihydroergotamine and sumatriptan. Headaches ceased upon repositioning of the stimulator lower in the cervical spine. We postulate an effect of the device on the trigeminovascular system via the nucleus caudalis trigeminalis and/or spinal trigeminal tract.

Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up.

In this study 169 female office employees were interviewed and examined to determine the occurrence and severity of neck and shoulder symptoms. Forty-seven of those with symptoms who fulfilled the criteria taken as indicating need for treatment were enrolled in a controlled clinical trial and divided into two groups. One group participated in dynamic muscle training of neck and shoulder muscles (active physiotherapy). The other patients were treated by means of surface heat, massage, and stretching (passive physiotherapy). Pain in the neck and shoulder regions disappeared significantly more often just after active treatment as compared to passive treatment. Symptoms returned within three months in both groups. However, after 12 months, the incidence of headache was significantly less in the group that had received active physiotherapy. Maximal isometric muscle strength in relation to cervical lateral flexion and extension and grip strength and endurance force of shoulder muscles improved significantly after active physiotherapy, but only maximal isometric extension force increased significantly after passive physiotherapy. Numbers of tender points in neck and shoulder muscles decreased significantly after both types of physiotherapy. Pressure threshold levels increased but not significantly in both groups during treatment.

Neurophysiological explorations in cervicobrachial neuralgia.

The various electrophysiological techniques which can be used in cervicobrachial neuralgia and their respective advantages and limitations are described. Beside the conventional electromyography and electrostimulation techniques, the indications for radicular motor and somesthetic evoked potentials are discussed.