Cheiro-Oral syndrome.

The Cheiro-Oral (COS) Syndrome is a rare neurologic condition characterized by sensory disturbances involving the peri-oral area and the upper extremity, typically isolated to the hand or fingers. The thalamus contralateral to the symptomatic side is the brain region most commonly involved. Most cases are caused by ischemic or hemorrhagic strokes, although other structural lesions have been implicated. These include tumors, subdural hematomas, aneurysms, and infections. The unusual and seemingly unrelated nature of the symptoms may contribute to misdiagnosis and incomplete workup for potentially serious conditions. We are unable to identify a report of this condition in the emergency medicine literature despite the emergency department being the likely point of presentation for patients with COS. In this report, we describe two patients with COS who presented to our emergency department and review the features of COS as described in published case reports.

Interrater Reliability of Osteopathic Sacral Palpatory Diagnostic Tests Among Osteopathy Students.

CONTEXT: Somatic dysfunctions are a key element of osteopathic practice. The evaluation of somatic dysfunctions is achieved by assessment of the TART (tissue texture abnormality, asymmetry, restriction of motion, tenderness) parameters. The reliability of a diagnostic method is the crux of successful treatment. Interrater reliability of osteopathic palpatory diagnostic tests have been studied on different anatomical areas, but there are no studies on the evaluation of all of the TART parameters on the sacrum. OBJECTIVE: To evaluate the interrater reliability of osteopathic sacral palpatory diagnostic tests. The hypothesis was that 3 trained osteopathy students at the end of their curriculum could achieve at least moderate agreement on osteopathic sacral palpatory diagnostic tests. METHODS: Three students from the Centre pour l'Étude, la Recherche et la Diffusion Ostéopathiques school in Rome, Italy, at the end of their curriculum participated as raters and received consensus training. Eligible subjects among students of the same school were recruited on a voluntary basis to be tested. All of the raters tested the sacrum by evaluating the TART parameters on every subject for 3 minutes. Raters were blinded to the other raters' findings. Interrater reliability was evaluated using Fleiss κ statistics. RESULTS: Fifty-two subjects (20 women) were enrolled in the study. Mean (SD) age was 25.9 (7.03) years; height, 1.73 (0.09) ms; weight, 68.73 (14.2) kg; and body mass index, 22.66 (3.58). Agreement was fair for tissue texture abnormality (κ=0.28), asymmetry (κ=0.29), restriction of motion (κ=0.32), and tenderness (κ=0.34); agreement was slight for landmark position (κ=0.06) and diagnosis of somatic dysfunction (κ=0.17). CONCLUSION: Results showed a level of agreement ranging from slight to fair in the assessment of the TART parameters among raters, who were in their last year of osteopathy school. The tenderness parameter was the most reliable. Our findings are consistent with other interrater reliability studies carried out in different body regions, contributing to show an overall heterogeneous level of diagnostic reliability in osteopathy.

Use of hypnosis, meditation, and biofeedback in dermatology.

Hypnosis utilizes trance to access otherwise inaccessible repressed or unconscious memories and features of the psyche and control of physiology not attainable in the ordinary conscious waking state. Medical uses of hypnosis in dermatology include reducing discomfort from itching or skin pain, altering ingrained dysfunctional habits such as scratching, promoting healing of skin disorders, searching for psychosomatic aspects of skin disorders and alleviating them, and reframing cognitive and emotional dysfunctional patterns related to skin disorders. Meditation uses trance to center and balance. Medical uses of meditation in dermatology include relaxation to promote healing of skin disorders and refocusing with respect to the meaning and emotional negative valance of skin disorders. Biofeedback in dermatology employs instrumentation with visual or auditory feedback to permit conscious awareness and alteration of physiologic phenomena such as sweating as measured by galvanic skin resistance and skin temperature measured by temperature detecting devices, promoting relaxation and healing. These methods and techniques permit access to and intervention in otherwise inaccessible areas that can influence skin disorders. With proper use, they are very safe, with minimal, if any, side effects and sometimes produce significant results where other methods have failed.

Somatosensory pain is not reliably modulated by weak acoustic stimuli.

BACKGROUND: Pain induced by electrical stimuli has been found in previous research to be reduced by brief, weak electrical pulses, termed prepulses, presented 40 to 60ms prior to the painful electrical stimulus. METHODS: The present experiment investigated the generality of this effect by presenting weak acoustic stimuli simultaneously with, or 80 or 1000ms prior to, painful electric shocks. In the second half of the experimental session, each participant (N=119) was told that the acoustic stimuli would either increase or decrease the pain induced by the electric shock, to investigate automatic and controlled cognitive processes in the modulation of pain. RESULTS: Acoustic stimuli presented simultaneously with painful stimulation increased pain slightly (4mm on a 100mm scale). Acoustic stimuli presented 80 and 1000ms prior to painful stimuli had no effect on pain. Information that acoustic stimuli would increase pain did so in females, but only when the acoustic stimulus was presented 80ms prior to the painful stimulus. CONCLUSIONS: The effect of the acoustic stimuli and of information was weak. Failure to replicate previous findings of decreased pain by weak prepulses was most likely due to the sensory modality of the prepulse stimuli. It is recommended that further studies of pain modulation by brief stimulation use electrical and not acoustic prepulse stimuli.

Managing iatrogenic trigeminal nerve injury: a case series and review of the literature.

This study describes the management of 216 patients with post-traumatic iatrogenic lingual nerve injuries (LNIs; n=93) and inferior alveolar nerve injuries (IANI; n=123). At initial consultation, 6% IANI and 2% LNI patients had undergone significant resolution requiring no further reviews. Reassurance and counselling was adequate management for 51% IANI and 55% LNI patients. Systemic or topical medication was offered as pain relief to 5% of patients. Additional cognitive behaviour therapy (CBT) was offered to 8% of patients. Topical 5% lidocaine patches reduced pain and allodynia in 7% of IANI patients, most often used without any other form of management. A small percentage of IANI patients (4%) received a combination of therapies involving CBT, surgery, medication and 5% lidocaine patches. Exploratory surgery improved symptoms and reduced neuropathic area in 18 LNI and 15 IANI patients resulting in improved quality of life. In conclusion, the authors suggest a more diverse and perhaps holistic strategy for management of patients with iatrogenic trigeminal nerve injuries and recommend pragmatic assessment criteria for measurement of treatment success in these patients.

Exploration of somatosensory impairments in subjects with mechanical idiopathic neck pain: a preliminary study.

OBJECTIVES: The purpose of this study was to investigate the differences in pressure and thermal pain hypersensitivity between patients with acute and chronic neck pain and healthy subjects. METHODS: Five patients with acute neck pain, 7 patients with chronic neck pain, and 6 matched controls participated. Pressure pain thresholds (PPTs) were assessed over the supraorbital, infraorbital, mental, median, ulnar, and radial nerves; the C5-C6 zygapophyseal joint; the second metacarpal; and the tibialis anterior muscle by an assessor blinded to the subjects' condition. Head pain threshold and cold pain threshold (CPT) were measured over the cervical region and over the tibialis anterior muscle. RESULTS: The analysis of variance found significant differences between groups, but not between sides, for PPT over the supraorbital, mental, median, ulnar and radial nerves; the C5-C6 joint; the second metacarpal; and the tibialis anterior muscle: patients with chronic neck pain showed bilateral lower PPTs as compared with controls (P < .01). Patients with acute neck pain also showed lower PPT (P < .01) over the median and ulnar nerves. No significant differences between groups or sides for head pain threshold over the cervical area or the tibialis anterior muscle were found. Significant differences between groups, but not between sides, for CPT over the neck and the tibialis anterior muscles were found: CPT was also reduced in patients with chronic, but not acute, neck pain (P < .01). CONCLUSIONS: We found widespread decreased PPT in patients with chronic, but not acute, mechanical neck pain as compared with controls. Patients with chronic neck pain also showed cold pain hypersensitivity as compared with patients with acute neck pain and controls. These results support the existence of different sensitization mechanisms between patients with acute and chronic mechanical insidious neck pain.

Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control.

The receptors in the cervical spine have important connections to the vestibular and visual apparatus as well as several areas of the central nervous system. Dysfunction of the cervical receptors in neck disorders can alter afferent input subsequently changing the integration, timing and tuning of sensorimotor control. Measurable changes in cervical joint position sense, eye movement control and postural stability and reports of dizziness and unsteadiness by patients with neck disorders can be related to such alterations to sensorimotor control. It is advocated that assessment and management of abnormal cervical somatosensory input and sensorimotor control in neck pain patients is as important as considering lower limb proprioceptive retraining following an ankle or knee injury. Afferent information from the cervical receptors can be altered via a number of mechanisms such as trauma, functional impairment of the receptors, changes in muscle spindle sensitivity and the vast effects of pain at many levels of the nervous system. Recommendations for clinical assessment and management of such sensorimotor control disturbances in neck disorders are presented based on the evidence available to date.

Occupational therapy using a sensory integrative approach: a case study of effectiveness.

OBJECTIVE: This article presents a case report of a child with poor sensory processing and describes the disorders impact on the child's occupational behavior and the changes in occupational performance during 10 months of occupational therapy using a sensory integrative approach (OT-SI). METHOD: Retrospective chart review of assessment data and analysis of parent interview data are reviewed. Progress toward goals and objectives is measured using goal attainment scaling. Themes from parent interview regarding past and present occupational challenges are presented. RESULTS: Notable improvements in occupational performance are noted on goal attainment scales, and these are consistent with improvements in behavior. Parent interview data indicate noteworthy progress in the child's ability to participate in home, school, and family activities. CONCLUSION: This case report demonstrates a model for OT-SI. The findings support the theoretical underpinnings of sensory integration theory: that improvement in the ability to process and integrate sensory input will influence adaptive behavior and occupational performance. Although these findings cannot be generalized, they provide preliminary evidence supporting the theory and the effectiveness of this approach.

Bimanual circling in deafferented patients: evidence for a role of visual forward models.

The present study investigated the role of ideation and visual feedback, and their interaction in movement control in the absence of somatosensory feedback, with the hypothesis that visual imagery and internal visual models may play a crucial role in performance even without feedback. Two chronically deafferented participants, GL and IW, circled bimanually two occluded cranks first without vision and then with hand-congruent and hand-incongruent visual feedback provided by visible flags. Without vision, GL was unable to circle the cranks. In contrast, IW performed spontaneously a symmetric pattern. Again without feedback, IW performed an instructed symmetric crank pattern well, but was unable to perform anti-phase cranking. With hand-congruent visual feedback, GL and IW were able to perform both symmetric and anti-phase movements, with symmetry being more accurate. Visual feedback during preceding trials made possible trials without visual feedback in GL and improved anti-phase trials in IW. Frequency-transformed incongruent visual feedback resulted in poor performance in part due to unsuitable hand-related strategies. However, IW improved in the latter task after detailed explanations of the condition. In conclusion, we suggest that both participants use visual imagery and visual forward models to control their hand movements. Visual updating of the forward model also improves performance with no vision. In addition, IW seemed to have been able to move from a focus on hand position to one on the transformed visual feedback to improve movement control in the incongruent feedback/movement condition.

Skin test results and self-reported symptom severity in allergic rhinitis: The role of psychological factors.

BACKGROUND: In allergic conditions, the degree of skin test reactivity does not always correlate with the severity of clinical symptoms. Additional factors may contribute to the reported symptom severity. OBJECTIVES: To investigate the association between the magnitude of the skin prick test (SPT) response and the reported symptom severity in patients with allergic rhinitis and the possible modifying role of psychological factors. METHODS: One hundred four patients with allergic rhinitis and 23 with non-allergic rhinitis, classified according to their SPT response to 19 aeroallergens, were asked to rate the severity of five symptoms and to indicate whether their symptoms intensified on exposure to five common aeroallergens. They also completed a psychological questionnaire. Results Reported symptom severity of allergic rhinitis did not correlate with weal size for any of the aeroallergens tested or with the number of positive responses on SPT. It was not related to patient age, sex, or education. The reported symptoms severity correlated positively (0.29, P < 0.01) with reported symptom intensification on exposure to allergens. Moreover, both outcomes were positively associated with the psychological factors of hypochondriasis (0.20, P < 0.05 and 0.18, P < 0.05, respectively), and somatic awareness (0.24, P < 0.05 and 0.33, P < 0.01, respectively), but not with neuroticism. CONCLUSIONS: The severity of symptoms experienced by patients with allergic rhinitis is apparently not related to the magnitude of SPT response, but rather to psychological factors of hypochondriasis and somatic awareness. Physicians should be aware of the contribution of psychological factors to patient perceptions of the intensity of symptoms and of the intensification of symptoms on their exposure to allergens.

Assessment of the perceptual threshold of touch (PTT) with high-frequency transcutaneous electric nerve stimulation (Hf/TENS) in elderly patients with stroke: a reliability study.

OBJECTIVE: To evaluate the inter-rater reliability and reliability between occasions of assessing the perceptual threshold of touch (PTT) with high-frequency transcutaneous electric nerve stimulation (Hf/TENS) in elderly patients with stroke. DESIGN: A test-retest study of reliability using intraclass correlation coefficient (ICC) and limits of agreement. SETTING: Geriatric rehabilitation unit. SUBJECTS: Thirty-two consecutive patients with stroke > or = 65 years of age. MAIN OUTCOME MEASURES: Two-channel current stimulator TENS CEFAR Tempo with four self-adhesive skin electrodes. The stimulator delivered a high-frequency constant current of 40 Hz. The strength of the stimulation was quantifiable and assessed in milliampere (mA). INTERVENTIONS: The assessments were performed on the hands and feet by two raters. The PTT was identified as the level registered in milliampere (mA) at which the patients perceived a tingling sensation. RESULTS: The ICC values (0.94-0.99) were shown to be good for inter-rater reliability, as well as reliability between occasions. However an additional analysis with limits of agreement showed a high level of agreement for assessment of the hand but a moderate to low agreement for assessment of the foot where some bias was also identified. Clinical acceptable reliability: > or = 1 mA for the hand and > or = 5 mA for the foot are so far recommended for establishing real differences in clinical measures. CONCLUSION: Hf/TENS shows an overall high reliability for assessing the PTT of the hand and moderate to low reliability for the foot. Additional research with exclusion of bias is needed to determine the reliability of assessing the foot.

Effect of neck pain on verticality perception: a cohort study.

OBJECTIVE: To use the Rod-and-Frame Test (RFT) as a quantification of the perception of verticality in subjects with and without neck pain. DESIGN: Cohort study comparing perception of verticality in symptomatic subjects with neck pain versus a control group. SETTING: Both groups were selected from 2 urban chiropractic offices treating typical neuromusculoskeletal conditions from the general community in Canada. PATIENTS: Nineteen subjects (11 women, 8 men) with uncomplicated mechanical neck pain and 17 (7 women, 10 men) asymptomatic subjects. INTERVENTION: The RFT offers a noninvasive method of measuring spatial orientation or the perception of verticality. Studies of the RFT indicate that performance is reliable. The RFT requires subjects to set a luminescent rod to the true vertical in the presence and absence of a luminescent background frame. MAIN OUTCOME MEASURE: The amount of rotation was measured and recorded by a dial on the back of the device. RESULTS: Two-way analysis of variance showed statistically significant differences in judging vertical between symptomatic and asymptomatic subjects. Unpaired t tests for each test situation and the Tukey post hoc test showed statistical differences for both groups. CONCLUSION: There may be a direct connection between the structures that provide internal cues for the body's ability to sense verticality and nociceptive influences affecting the afference of these structures. The overshoot of the symptomatic group could indicate the search for additional proprioceptive information.