Cervical Lateral Glide Neural Mobilization Is Effective in Treating Cervicobrachial Pain: A Randomized Waiting List Controlled Clinical Trial.

BACKGROUND: Cervicobrachial pain (CP) is a high-incidence and prevalent condition. Cervical lateral glide (CLG) is a firstline treatment of CP. There is a current lack of enough high-quality randomized controlled double-blind clinical trials that measure the effectiveness of neural tissue mobilization techniques such as the CLG and its specific effect over CP. OBJECTIVES: The aim of the present study was to assess the effect of CLG neural mobilization in treating subjects who suffer from CP, compared with the complete absence of treatment. STUDY DESIGN: This investigation was a single-center, blinded, parallel randomized controlled clinical trial (RCT). SETTING: One hundred forty-seven individuals were screened in a medical center from July to November 2015. Fifty-eight participants were diagnosed with CP. METHODS: Participants were recruited and randomly assigned into two groups of 29 subjects. The intervention group received CLG treatment, and the control group (CG) was assigned to a six-week waiting list to receive treatment. Randomization was carried out by concealed computer software randomized printed cards. The primary outcome was pain intensity, reported through the Numeric Rating Scale for Pain (NRSP). Secondary outcomes were physical function involving the affected upper limb using the Quick DASH scale and ipsilateral cervical rotation (ICR) using a CROM device. Assessments were made at baseline and one hour after treatment. RESULTS: The CLG group NRSP mean value was significantly (P < 0.0001) superior to those obtained by the CG. Subjects treated with CLG reported an average NRSP decrease of 2.16 points (35%). CROM device and Quick DASH outcome values also reported significant (P < 0.0001) improvements only in the CLG group. Cohen's d showed a very large effect of the CLG intervention at subject discharge. LIMITATIONS: Due to the lack of dipper subgroup analysis and additional reproductions of the applied protocol, the authors considered the generalization of the study results to be impossible. CONCLUSIONS: CLG is superior to the absence of treatment in reducing pain and increasing the affected upper limb function of subjects who suffer from CP. CLG may be considered an effective treatment in specific cases of CP.

Residual complaints after neuralgic amyotrophy.

OBJECTIVE: To develop recommendations regarding outcome measures and topics to be addressed in rehabilitation for persons with neuralgic amyotrophy (NA), this study explored which functions and activities are related to persisting pain in NA and which questionnaires best capture these factors. DESIGN: A questionnaire-based survey from 2 cross-sectional cohorts, one of patients visiting the neurology outpatient clinic and a cohort seen at a multidisciplinary plexus clinic. SETTING: Two tertiary referral clinics based in the Department of Neurology and Rehabilitation from a university medical center provided the data. PARTICIPANTS: A referred sample of patients (N=248) with either idiopathic or hereditary NA who fulfilled the criteria for this disorder, in whom the last episode of NA had been at least 6 months ago and included brachial plexus involvement. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two custom clinical screening questionnaires were used as well as the Shoulder Rating Questionnaire-Dutch Language Version, the Shoulder Pain and Disability Index (SPADI), the Shoulder Disability Questionnaire (SDQ), and Overall Disability Sum Score. RESULTS: The survey confirms the high prevalence of persisting pain and impairments. More than half of the patients were restricted by pain, while in those without pain 60% experienced residual paresis. Correlations show an intimate relation between pain, scapular instability, problems with overhead activities, and increased fatigability. A standard physical therapy approach was ineffective or aggravated symptoms in more than 50%. CONCLUSIONS: Pain and fatigue are strongly correlated to persisting scapular instability and increased fatigability of the affected muscles in NA. Our results suggest that an integrated rehabilitation approach is needed in which all of these factors are addressed. We further recommend using the SPADI and SDQ in future studies to evaluate the natural course and treatment effects in NA.

Parsonage-Turner Syndrome After SARS-CoV-2 BNT162b2 Vaccine: A Case Report.

CASE: Parsonage-Turner syndrome, also known as brachial neuritis or neuralgic amyotrophy, is characterized by sudden-onset pain and subsequent weakness of the shoulder. Known precipitating factors include viral and bacterial infections and certain immunizations. Isolated cases after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported. We report the case of a 66-year-old woman with right shoulder dysfunction and medial scapular winging after immunization with the SARS-CoV-2 BNT162b2 vaccine (Pfizer). CONCLUSION: After physical therapy, the patient resumed her normal activities of daily living. Findings from this case represent the first known documentation of Parsonage-Turner syndrome after SARS-CoV-2 BNT162b2 vaccination.

[Neuralgic amyotrophy as the primary cause of shoulder pain in a patient with rotator cuff tear]. / Rotator manset yirtigi olan bir olguda omuz agrisinin ana nedeni: Nöraljik amiyotrofi.

A 66-year-old woman with no history of trauma presented with severe shoulder pain. Magnetic resonance imaging revealed rupture of the supraspinatus tendon, for which surgical treatment was considered. However, it was noted that shoulder pain was accompanied by weakness in the shoulder muscles, and the patient underwent electroneuromyographic examination, which revealed neuralgic amyotrophy. Following physical therapy and rehabilitation combined with appropriate medical therapy, her symptoms significantly improved. In cases with severe shoulder pain without a trauma history, characteristics of pain should be thoroughly analyzed and neuralgic amyotrophy considered in the differential diagnosis.

Reflections of patients and therapists on a multidisciplinary rehabilitation programme for persons with brachial plexus injuries.

PURPOSE: There is lack of knowledge, evidence, and guidelines for rehabilitation interventions for persons with neuralgic amyotrophy (NA) or brachial plexus pathology. A first pilot study, evaluating the effect of an integrated rehabilitation programme, showed improvements in activity and participation levels. AIM: To gain insight, from the perspective of patients and therapists, into the critical ingredients of the programme, that contributed to improvements in activity and participation. MATERIALS AND METHODS: A qualitative study using semi-structured interviews with eight patients and five therapists (three occupational therapists and two physical therapists). Participants were asked to identify and describe factors regarding the rehabilitation that they perceived as positive and aspects of the programme that could be improved. Data were analysed using a constant comparative approach. RESULTS: Patients reported (1) Time to diagnose: "Finally I'm in the right place;" (2) Awareness: "They gave me a mirror;" (3) Partnership: "There was real contact with the therapists; we made decisions together;" (4) Close collaboration: "Overlapping scopes of practice; doing the same from a different perspective;" and finally (5) Self-management: "Now I can do it myself." Therapists reported (1) "Patients knowledge and understanding is critical to success;" (2) "Activate problem solving and decision making;" (3) "Personalize your therapy; it's more than just giving exercises and information;" (4) "Constant consultation within the team; consistency in messages and approach;" and (5)" Ultimately the patient is in charge." CONCLUSIONS: The critical ingredients, correspond well with each other and include a person-centred approach, education, support in problem solving and decision making and an integrated team approach. These ingredients provided the patients with confidence to take responsibility to manage their everyday lives, the ultimate goal of the programme. Implications for rehabilitation Both patients and therapists believe that the ability to self-manage and take control should be the outcome of high quality integrated rehabilitation programmes for patients with neuralgic amyotrophy and/or other brachial plexus injuries. A person-centred, collaborative, and integrated team approach, among all members of the team, are critical components of care delivery in personalised interventions. Critical programme ingredients are knowledge and education of both the patient and therapists; partnership between patient-therapist and within the team; patient activation and self-reflection; and personalised care. Patients recommend more options for personalisation of the intensity and duration of rehabilitation, the possibility to consult a psychologist and peer support within a group setting.

NA-CONTROL: a study protocol for a randomised controlled trial to compare specific outpatient rehabilitation that targets cerebral mechanisms through relearning motor control and uses self-management strategies to improve functional capability of the upper extremity, to usual care in patients with neuralgic amyotrophy.

BACKGROUND: Neuralgic amyotrophy (NA) is a distinct peripheral neurological disorder of the brachial plexus with a yearly incidence of 1/1000, which is characterised by acute severe upper extremity pain. Weakness of the stabilising shoulder muscles in the acute phase leads to compensatory strategies and abnormal motor control of the shoulder - scapular dyskinesia. Despite peripheral nerve recovery, scapular dyskinesia often persists, leading to debilitating residual complaints including pain and fatigue. Evidence suggests that persistent scapular dyskinesia in NA may result from maladaptive cerebral neuroplasticity, altering motor planning. Currently there is no proven effective causative treatment for the residual symptoms in NA. Moreover, the role of cerebral mechanisms in persistent scapular dyskinesia remains unclear. METHODS: NA-CONTROL is a single-centre, randomised controlled trial comparing specific rehabilitation to usual care in NA. The rehabilitation programme combines relearning of motor control, targeting cerebral mechanisms, with self-management strategies. Fifty patients will be included. Patients are recruited through the Radboud university medical center Nijmegen, the Netherlands. Patients with a (suspected) diagnosis of NA, with lateralized symptoms and scapular dyskinesia in the right upper extremity, who are 18 years or older and not in the acute phase can be included. The primary outcome is the Shoulder Rating Questionnaire score, which measures functional capability of the upper extremity. Secondary clinical outcomes include measures of pain, fatigue, participation, reachable workspace, muscle strength and quality of life. In addition, motor planning is assessed with first-person motor imagery and functional magnetic resonance imaging. In a sub-study the patients are compared to 25 healthy participants, to determine the involvement of cerebral mechanisms. This will enable interpretation of cerebral changes associated with the rehabilitation programme and functional impairments in NA. DISCUSSION: NA-CONTROL is the first randomised trial to investigate the effect of specific rehabilitation on residual complaints in NA. It also is the first study into the cerebral mechanisms that might underlie persistent scapular dyskinesia in NA. It thus may aid the further development of mechanism-based interventions for disturbed motor control in NA and in other peripheral neurological disorders. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03441347 . Registered on 20 February 2018.

Sustained effects of comprehensive inpatient rehabilitative treatment and sleeping neck support in patients with chronic cervicobrachialgia: a prospective and randomized clinical trial.

The objective of this study was to investigate the long-term efficacy of inpatient rehabilitation using sleeping neck support in patients suffering from chronic cervicobrachialgia. A prospective, randomized clinical trial with a 12-month follow-up was done. A total of 149 patients suffering from chronic cervicobrachialgia received a 4-week inpatient rehabilitation programme. The patients were randomly divided into two groups. The patients in one group were given a special neck pillow to use during and after the rehabilitative treatment (n=76); the patients in the other group were not given the pillow (n=73). Two weeks before, during, and after (3, 6, 9, and 12 months) the 4-week treatment period, the patients completed a questionnaire dealing with the intensity of their cervicobrachial complaints (pain intensity, muscular tension, paraesthesia, and sleep disorders caused by pain or paraesthesia). During the inpatient treatment period, no significant differences were detected between the groups; however, 1-12 months after discharge, the group with sleeping neck support showed a significantly (P<0.05) smaller increase in the intensity of cervical spine pain. Sleep disturbances caused by pain were also reduced significantly (P<0.001 after 3 months, respectively, P<0.05 after 12 months). Inpatient rehabilitative treatment has sustained effects in patients suffering from chronic cervicobrachialgia, particularly when a sleeping neck support is added.

Challenging Diagnosis and Inpatient Rehabilitation of Acute Bilateral Neuralgic Amyotrophy Possibly Attributed to Lyme Disease: A Case Report.

Neuralgic amyotrophy (NA) is a neurologic syndrome of unknown etiology primarily affecting the brachial plexus. We are reporting an unusual case of acute bilateral NA that was possibly secondary to Lyme disease. The patient demonstrated significant functional gains and was discharged home after 2 weeks of inpatient rehabilitation, supporting the role of inpatient rehabilitation in acute NA. In this report, we discuss the diagnosis, electrodiagnostic progression, pain management, goals for inpatient rehabilitation, and overall prognosis of NA. LEVEL OF EVIDENCE: V.

[Parsonage-Turner Syndrome - Case Report]. / Das Parsonage-Turner-Syndrom.

Neuralgic amyotrophy of the shoulder (Parsonage-Turner syndrome) is a rare condition of unknown aetiology which manifests as acute neuropathy of the brachial plexus. Diagnosis is based on typical symptoms and physical examination. In addition, magnetic resonance imaging of the affected shoulder and the cervical spine is advisable, in order to distinguish this syndrome from other conditions with similar symptoms. There is no specific treatment for neuralgic amyotrophy, but in about 50 - 67% of cases complete recovery occurs within two to three years, depending on the severity of the symptoms when they first appear. In patients whose strength and function are not fully restored, neurological deficits may remain, especially if the same shoulder is affected by recurrent attacks.

Chronic cervical pain: radiculopathy or brachialgia. Noninterventional treatment.

Chronic cervical pain is not always attributable to radiculopathy. Pain may derive from peripheral myofascial syndromes and/or central inflammatory root irritation from degradation of discal proteoglycans. This concept is presented with its application in 30 patients with follow-up observations up to 30 months. Twelve of twenty-five achieving a pain level of 0 (out of a possible 10), ten of twenty-five had a pain level of 2, and three of twenty-five had a pain level of 4. Five cases were considered to be failures because of patient noncompliance. Treatment was multidisciplinary: aggressive physical medicine, behavioral medicine, vocational, and recreational rehabilitation with the goal of a return to socioeconomic productivity or previous lifestyle, secondary to which pain relief or control follows. Emphasis was placed on the restoration of musculoskeletal physiology to normal with behavioral modification, good body mechanics and the application of engineering/ergonomic principles at work or recreation.

Physical therapy management of isolated serratus anterior muscle paralysis.

This case report presents a patient who developed right shoulder pain following strenuous upper-extremity exercise. Approximately 6 weeks later his pain resolved, he noticed persistent right upper-extremity weakness. He was referred to physical therapy for evaluation and treatment. Physical therapy evaluation revealed isolated serratus anterior muscle paralysis. A long thoracic neuropathy was subsequently confirmed by electromyographic testing. The etiology, pathophysiology, and pathokinesiology of serratus anterior muscle paralysis are reviewed. A case is presented, illustrating how the clinical decision making is based on the pathokinesiology and pathophysiology. The patient was followed over the course of 17 months and has recovered full right shoulder active range of motion. His serratus anterior muscle strength has increased to Good minus, and he reports significantly improved functional use of the upper extremity.

Nerve trunk pain: physical diagnosis and treatment.

The management of peripheral neuropathic pain or nerve trunk pain relies upon accurate differential diagnosis. In part neurogenic pain has been attributed to increased activity in, as well as to abnormal processing of non-nociceptive input from, the nervi nervorum. For neurogenic pain to be identified as the dominant feature of a painful condition there should be evidence of increased nerve trunk mechanosensitivity from all aspects of the physical examination procedure. Consistent dysfunction should be identified on key active and passive movements, neural tissue provocation tests as well as nerve trunk palpation. A local cause for the neurogenic pain disorder should also be identified if the condition is to be treated by manual therapy. A treatment approach is presented which has been shown to have efficacy in the relief of pain and restoration of function in cervicobrachial pain disorders where there is evidence according to the outlined examination protocol of nerve trunk pain.

[Brachial plexus neuropathy following pyogenic cervical adenophlegmon]. / Névralgie brachiale amyotrophiante au décours d'un adénophlegmon cervical à pyogènes.

BACKGROUND: Brachial plexopathy is rare in children; it may follow a non-specific respiratory infection or occur after a specific viral disease or immunization. CASE REPORT: An 8 year-old girl was admitted suffering from presuppurative acute cervical adenitis. She was given penicillin V, netilmicin and corticosteroids. The adenitis gradually resolved over a period of ten days. There was no evidence of a specific bacterial infection. The patient suffered from pain localized to her right shoulder 15 days after admission; this pain was resolved within 3-4 days but was followed by paralysis affecting the upper brachial roots without sensory signs. EMG performed 15 days later showed signs of denervation. Amyotrophy set in rapidly but recovery under physiotherapy was complete 5 months later. CONCLUSION: This plexopathy resembling the Parsonage-Turner syndrome could be allergic in pathogenesis although similar cases after bacterial, possibly streptococcal, infection remain to be confirmed.

[Interference therapy and radon baths in the combined treatment of patients with reflex cervicobrachial syndromes]. / Interferentsterapiia i radonovye vanny v kompleksnom lechenii bol'nykh s reflektornymi tservikobrakhialgicheskimi sindromami.

Patients with cervicobrachialgic syndromes on interference therapy, exercise treatment, massage of the cervical collar region received balneotherapy. 42 of them took water baths, 39 took dry air radon baths. These complexes proved effective in cervicobrachialgic syndromes, the effect being slightly dependent on the clinical symptoms of the disease.

Scapular kinematics and muscle performance in a single case of Parsonage-Turner.

This study characterized the impairments of range of motion, three-dimensional scapulo-thoracic kinematics, isokinetic muscle performance and disability in a patient with Parsonage-Turner Syndrome. The patient had a history of 2.5-years of shoulder pain, and electroneurodiagnostic testing indicative of suprascapular neuropathy. The patient-rated Disabilities of the Arm, Shoulder and Hand (DASH) score was 33.3% (0 = no symptoms/disability), and reduced shoulder internal rotation, external rotation, and flexion as compared bilaterally. There were deficits in isokinetic muscle performance at slow and fast speeds during abduction, lateral and medial rotations as compared to the uninvolved side. Alterations in scapular kinematics were decreased posterior tilt, increased internal rotation, and increased upward rotation during arm elevation and lowering. This information can be used to assist clinicians in developing treatment programs to address the alterations caused by this neuralgic amyotrophy.

Efficacy of a combined physical and occupational therapy intervention in patients with subacute neuralgic amyotrophy: a pilot study.

BACKGROUND: Neuralgic Amyotrophy (NA) is characterized by neuropathic pain, subsequent patchy paresis and possible sensory loss in the upper extremity. Many patients experience difficulties in performing activities of daily life and are unable to resume work. We developed a combined physical- and occupational therapy program for patients recovering from NA. OBJECTIVE: Evaluation of the effectiveness of a multidisciplinary intervention program for patients with subacute NA. METHODS: We performed a within subject proof-of-principle pilot study in eight patients with subacute NA. Patients followed 8 hours of physical and 8 hours of occupational therapy spread over a 16-week period. PRIMARY OUTCOME MEASURES: The Canadian Occupational Performance Measure (COPM) and Shoulder Rating Questionnaire (SRQ). SECONDARY OUTCOME MEASURE: Disability of Arm Shoulder and Hand (DASH). RESULTS: Improvements (mean (95% CI)) were found in the performance and satisfaction scores of the COPM +2.3 (0.9-3.7) and +1.4 (0.4-2.4) points, respectively and the SRQ +14.8 (7.4-22.0) points. The majority of patients (6 out of 8) also demonstrated improvements in the DASH. CONCLUSION: The proposed physical and occupational therapy program, may be effective for patients with subacute NA, as demonstrated by improvements in activity, performance and participation.