Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System.

OBJECTIVE: Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. METHODS: We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. RESULTS: The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. CONCLUSION: The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System / Lesões do nervo facial relacionadas à parotidectomia: proposta de um sistema Sunnybrook de graduação facial modificado

ABSTRACT Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. Objective To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. Methods We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. Results The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. Conclusion The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

RESUMO A lesão do nervo facial é a principal complicação neurológica relacionada às parotidectomias e, em geral, o ramo marginal mandibular é o mais frequentemente acometido. Objetivo Testar um Sistema Sunnybrook de Graduação Facial modificado (mS-FGS) como uma nova ferramenta para avaliar a função do nervo facial após a parotidectomia, enfatizando o ramo marginal mandibular. Métodos Estudo retrospectivo, baseado em prontuários de 73 casos (40 do sexo feminino, 18-84 anos, idade média = 53,2), submetidos à parotidectomia, com preservação do nervo facial. Todos os pacientes apresentavam neoplasias parotídeas ou câncer de pele avançado, e foram tratados pela autora principal entre 2006 e 2014. Resultados Neste estudo, os músculos inervados pelo ramo marginal mandibular foram os mais acometidos (72,6% dos casos), principalmente nos pacientes que realizaram esvaziamento cervical (p = 0,023). Os Escores de Movimento Voluntário obtidos pelo sistema modificado foram inferiores aos obtidos pelo original (p < 0,001). As melhores pontuações foram observadas em pacientes com tumores benignos parotídeos e os piores resultados, naqueles com câncer de pele. Pacientes que necessitaram de esvaziamento cervical e ressecção de outras estruturas, além da parótida, apresentaram escores menores (p = 0,031 e p = 0,021), evidenciados apenas pelo sistema modificado. Os tumores malignos geraram escores significativamente menores, independentemente do instrumento empregado. A análise pós fisioterapia envolveu 50 casos. Os piores resultados, após a intervenção fisioterapêutica, também foram observados nos músculos inervados pelo ramo marginal mandibular. Conclusão A avaliação da disfunção facial pós-parotidectomia, através do Sistema Sunnybrook com a modificação proposta permitiu uma apreciação mais detalhada do ramo marginal mandibular, sem prejuízo à avaliação dos demais ramos.

Recommendations for the treatment of migraine attacks - a Brazilian consensus.

In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period.

Assessment of otoacoustic emission suppression in women with migraine and phonophobia.

Given that the medial olivocochlear efferent system reduces the amplitude of otoacoustic emissions (OAE), the aim of this study was to establish whether such a pathway is affected in women with migraine and phonophobia by means of OAE suppression testing. In this prospective case-control study, 55 women (29 with migraine and phonophobia and 26 healthy women) were subjected to transient-evoked otoacoustic emission (TEOAE) testing at frequencies from 1 to 4 kHz. The amplitudes of the TEOAE response before and after exposure to contralateral noise and the magnitude of TEOAE suppression were assessed. The average TEOAE amplitudes in conditions with and without exposure to contralateral noise were not significantly different between the groups. However, the magnitude of TEOAE suppression was lower in the group with migraine; that difference was only statistically significant for frequencies 1 and 1.5 kHz (p = 0.042 and p = 0.004, respectively). In this study, women with migraine and phonophobia exhibited deficits in OAE suppression, which points to a disorder affecting the medial olivocochlear efferent system.

The minimal caloric test asymmetric response in vertigo-free migraine patients.

Vertigo symptoms and subclinical vestibular dysfunctions may occur in migraine. The Minimal Caloric Test (MCT), an easy-to-perform, convenient and yet informative procedure was used to test the vestibular function in 30 vertigo-free migraine patients outside attacks and 30 paired controls. Although not statistically significant, a right-to-left nystagmus duration asymmetry greater than 25% was present in both groups. This difference was greater in the patients group, suggesting the presence of subclinical vestibular imbalance in migraine.

Jumping to conclusions in untreated patients with Parkinson's disease.

BACKGROUND: Jumping to conclusions due to impulsivity has been shown to be a sensitive marker for dopamine dysregulation and addictive behaviour patterns in treated patients with Parkinson's disease (PD). It is unknown whether drug naïve PD patients, who have never received dopaminergic therapy also have deficits in information sampling. METHODS: Twenty five de novo PD patients and twenty matched healthy controls were recruited and tested on the beads task, which is a validated information sampling task to assess reflection impulsivity and a temporal discounting questionnaire. RESULTS: Patients gathered significantly less information and made more irrational choices than matched controls. There was, however, no group difference on the temporal discounting questionnaire. CONCLUSIONS: Poor information sampling and irrational decision making may be an inherent component of the neuropsychological deficit in Parkinson's disease. These findings suggest that underlying impulsivity detected by a metric task is common in de novo PD.

Recommendations for the treatment of migraine attacks - a Brazilian consensus / Recomendações para o tratamento da crise migranosa - Um consenso brasileiro

ABSTRACT In this article, a group of experts in headache management of the Brazilian Headache Society developed through a consensus strategic measurements to treat a migraine attack in both the child and the adult. Particular emphasis was laid on the treatment of migraine in women, including at pregnancy, lactation and perimenstrual period.

RESUMO Neste artigo um grupo de especialistas no tratamento de cefaleia da Sociedade Brasileira de Cefaleia através de um consenso elaborou medidas estratérgicas para tratar uma crise de migrânea tanto na criança como no adulto. Uma enfase particular foi dada no tratamento da migranea na mulher, incluindo gravidez, lactação e período perimenstrual.

The minimal caloric test asymmetric response in vertigo-free migraine patients / A resposta assimétrica ao teste calórico mínimo nos pacientes com enxaqueca sem vertigem

ABSTRACT Vertigo symptoms and subclinical vestibular dysfunctions may occur in migraine. The Minimal Caloric Test (MCT), an easy-to-perform, convenient and yet informative procedure was used to test the vestibular function in 30 vertigo-free migraine patients outside attacks and 30 paired controls. Although not statistically significant, a right-to-left nystagmus duration asymmetry greater than 25% was present in both groups. This difference was greater in the patients group, suggesting the presence of subclinical vestibular imbalance in migraine.

RESUMO Vertigem e alterações vestibulares subclínicas têm sido identificadas na enxaqueca. O teste calórico mínimo é simples de realizar, informativo e conveniente. Ele foi realizado em 30 pacientes com enxaqueca sem queixa de vertigem e 30 controles pareados. Embora não estatisticamente significativo, ocorreu assimetria direita-esquerda superior a 25% na duração do nistagmo em ambos os grupos, maior nos pacientes, o que sugere a presença de desequilíbrio vestibular subclínico na enxaqueca.

Migraine patients consistently show abnormal vestibular bedside tests / Pacientes enxaquecosos consistentemente apresentam testes vestibulares de beira-de-leito anormais

Migraine and vertigo are common disorders, with lifetime prevalences of 16% and 7% respectively, and co-morbidity around 3.2%. Vestibular syndromes and dizziness occur more frequently in migraine patients. We investigated bedside clinical signs indicative of vestibular dysfunction in migraineurs. Objective To test the hypothesis that vestibulo-ocular reflex, vestibulo-spinal reflex and fall risk (FR) responses as measured by 14 bedside tests are abnormal in migraineurs without vertigo, as compared with controls. Method Cross-sectional study including sixty individuals – thirty migraineurs, 25 women, 19-60 y-o; and 30 gender/age healthy paired controls. Results Migraineurs showed a tendency to perform worse in almost all tests, albeit only the Romberg tandem test was statistically different from controls. A combination of four abnormal tests better discriminated the two groups (93.3% specificity). Conclusion Migraine patients consistently showed abnormal vestibular bedside tests when compared with controls.

Enxaqueca e vertigem são desordens comuns, com prevalência de 16% e 7% respectivamente, e comorbidade em torno de 3,2%. Síndromes vestibulares e tonturas ocorrem mais frequentemente em enxaquecosos. Pesquisamos alterações vestibulares utilizando testes de beira-de-leito em enxaquecosos. Objetivo Verificar se as respostas dos reflexos vestíbulo-ocular, vestíbulo-medular e risco de quedas medidas por 14 testes de beira-de-leito são diferentes comparando-se enxaquecosos sem vertigem, e controles. Método Estudo transversal com sessenta pessoas, 30 enxaquecosos; 25 mulheres, 19-60 anos; e trinta controles saudáveis pareados por sexo e idade. Resultados Houve tendência de pior desempenho entre enxaquecosos em quase todos testes, porém apenas o teste de Romberg tandem foi estatisticamente diferente dos controles. Uma combinação de quatro testes anormais discrimina os grupos com especificidade de 93,3%. Conclusão O grupo de enxaquecosos mostrou consistentemente testes vestibulares de beira-de-leito anormais quando comparados a controles.

Migraine patients consistently show abnormal vestibular bedside tests.

UNLABELLED: Migraine and vertigo are common disorders, with lifetime prevalences of 16% and 7% respectively, and co-morbidity around 3.2%. Vestibular syndromes and dizziness occur more frequently in migraine patients. We investigated bedside clinical signs indicative of vestibular dysfunction in migraineurs. OBJECTIVE: To test the hypothesis that vestibulo-ocular reflex, vestibulo-spinal reflex and fall risk (FR) responses as measured by 14 bedside tests are abnormal in migraineurs without vertigo, as compared with controls. METHOD: Cross-sectional study including sixty individuals - thirty migraineurs, 25 women, 19-60 y-o; and 30 gender/age healthy paired controls. RESULTS: Migraineurs showed a tendency to perform worse in almost all tests, albeit only the Romberg tandem test was statistically different from controls. A combination of four abnormal tests better discriminated the two groups (93.3% specificity). CONCLUSION: Migraine patients consistently showed abnormal vestibular bedside tests when compared with controls.

Neurological examination: pioneering authors and their books.

The objective of this article is to highlight some of the most important pioneering books specifically focused on the neurological examination and their authors. During the XIX Century, Alexander Hammond, William Gowers and Charles Mills pioneered the neurological literature, followed in the XX Century by Aloysio de Castro, Monrad-Krohn, Derek Denny-Brown, Robert Wartenberg, Gordon Holmes, and Russel DeJong. With determination and a marked sense of observation and research, they competently developed and spread the technique and art of the neurological exam.

Neurological examination: pioneering authors and their books / Exame neurológico: autores pioneiros e seus livros

The objective of this article is to highlight some of the most important pioneering books specifically focused on the neurological examination and their authors. During the XIX Century, Alexander Hammond, William Gowers and Charles Mills pioneered the neurological literature, followed in the XX Century by Aloysio de Castro, Monrad-Krohn, Derek Denny-Brown, Robert Wartenberg, Gordon Holmes, and Russel DeJong. With determination and a marked sense of observation and research, they competently developed and spread the technique and art of the neurological exam.

O objetivo deste artigo é destacar alguns dos primeiros e mais importantes livros-texto interessados em difundir o ensino do exame neurológico e seus autores. Durante o século XIX, Alexander Hammond, William Gowers e Charles Mills foram pioneiros na literatura neurológica, seguidos por Aloysio de Castro, Monrad-Krohn, Derek Denny-Brown, Robert Wartenberg, Gordon Holmes e Russel DeJong no século XX. Com determinação, grande senso de observação e pesquisa, eles competentemente disseminaram a técnica e a arte de se realizar o exame neurológico.

Aura-like features and photophobia in sightless migraine patients.

UNLABELLED: Migraine is a central nervous system disorder frequently expressed with paroxysmal visual dysfunctions. OBJECTIVE: To test the hypothesis that normal visual input is vital for the migrainous aura and photophobia. METHOD: We studied the migraine-related visual disturbances in 8 sightless migraineurs identified among 200 visually impaired subjects. RESULTS: The main findings were the visual aura and photophobia disappearance along with blindness development, the oddness of aura - too short, colourful (e.g. blue or fire-like), auditory in nature or different in shape (round forms) - and the lack of photophobia. CONCLUSION: We propose that the aura duration should be accepted as shorter in visually impaired subjects. The changes in aura phenotype observed in our patients may be the result of both cerebral plasticity induced by the visual impairment and/or the lack of visual input per se. Integrity of visual pathways plays a key role in migraine visual aura and photophobia.

Aura-like features and photophobia in sightless migraine patients / Características de fenômenos aura-relacionados e da fotofobia em enxaquecosos deficientes visuais

Migraine is a central nervous system disorder frequently expressed with paroxysmal visual dysfunctions. Objective To test the hypothesis that normal visual input is vital for the migrainous aura and photophobia. Method We studied the migraine-related visual disturbances in 8 sightless migraineurs identified among 200 visually impaired subjects. Results The main findings were the visual aura and photophobia disappearance along with blindness development, the oddness of aura – too short, colourful (e.g. blue or fire-like), auditory in nature or different in shape (round forms) – and the lack of photophobia. Conclusion We propose that the aura duration should be accepted as shorter in visually impaired subjects. The changes in aura phenotype observed in our patients may be the result of both cerebral plasticity induced by the visual impairment and/or the lack of visual input per se. Integrity of visual pathways plays a key role in migraine visual aura and photophobia. .

A enxaqueca é doença neurológica frequentemente associada a anormalidades visuais transitórias. Objetivo Testar a hipótese de que a visão normal é importante para o fenótipo da aura e da fonofobia. Método Estudamos 8 enxaquecosos deficientes visuais identificados em uma população de 200 indivíduos com visão subnormal. Resultados Os principais achados foram: o desaparecimento da aura visual e da fotofobia com o início da cegueira; a ocorrência de aura atípica – muito curta, colorida (p. ex. azul ou cor de fogo) auditiva ou diferente na forma (arredondadas); e a ausência de fotofobia. Conclusão Propomos que a duração da aura possa ser admitida como mais curta em pessoas com deficiência visual. As mudanças no fenótipo da aura observadas nos nossos pacientes pode ser o resultado da plasticidade cerebral induzida pela deficiência visual e/ou a deficiência visual em si. A integridade da via visual desempenha um papel crucial na aura enxaquecosa e na fotofobia. .

Conversive gait disorder: you cannot miss this diagnosis.

Bizarre, purposeless movements and inconsistent findings are typical of conversive gaits. The objective of the present paper is to review some phenomenological aspects of twenty-five consecutive conversive gait disorder patients. Some variants are typical - knees give way-and-recover presentation, monoparetic, tremulous, and slow motion - allowing clinical diagnosis with high precision.

Conversive gait disorder: you cannot miss this diagnosis / Distúrbio conversivo da marcha: você não pode deixar de fazer esse diagnóstico

Bizarre, purposeless movements and inconsistent findings are typical of conversive gaits. The objective of the present paper is to review some phenomenological aspects of twenty-five consecutive conversive gait disorder patients. Some variants are typical – knees give way-and-recover presentation, monoparetic, tremulous, and slow motion – allowing clinical diagnosis with high precision.

Movimentos bizarros, sem finalidade e inconsistentes são típicos das marchas conversivas. O objetivo deste artigo é descrever os aspectos fenomenológicos de vinte e cinco pacientes com distúrbio conversivo da marcha, salientando que algumas variantes são tão típicas – dobrando os joelhos e recuperando, monoparética, trêmula e em câmara lenta – que praticamente não possuem diagnóstico diferencial.

Proprioceptive neuromuscular facilitation in HTLV-I-associated myelopathy/tropical spastic paraparesis.

INTRODUCTION: Human T cell lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) can impact the independence and motricity of patients. The aims of this study were to estimate the effects of physiotherapy on the functionality of patients with HAM/TSP during the stable phase of the disease using proprioceptive neuromuscular facilitation (PNF) and to compare two methods of treatment delivery. METHODS: Fourteen patients with human T cell lymphotropic virus type I (HTLV-I) were randomly allocated into two groups. In group I (seven patients), PNF was applied by the therapist, facilitating the functional activities of rolling, sitting and standing, walking and climbing and descending stairs. In group II (seven patients), PNF was self-administered using an elastic tube, and the same activities were facilitated. Experiments were conducted for 1h twice per week for 12 weeks. Low-back pain, a modified Ashworth scale, the functional independence measure (FIM) and the timed up and go test (TUG) were assessed before and after the interventions. RESULTS: In the within-group evaluation, low-back pain was significantly reduced in both groups, the FIM improved in group II, and the results of the TUG improved in group I. In the inter-group analysis, only the tone was lower in group II than in group I. CONCLUSIONS: Both PNF protocols were effective in treating patients with HAM/TSP.

Proprioceptive neuromuscular facilitation in HTLV-I-associated myelopathy/tropical spastic paraparesis

Introduction: Human T cell lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) can impact the independence and motricity of patients. The aims of this study were to estimate the effects of physiotherapy on the functionality of patients with HAM/TSP during the stable phase of the disease using proprioceptive neuromuscular facilitation (PNF) and to compare two methods of treatment delivery. Methods: Fourteen patients with human T cell lymphotropic virus type I (HTLV-I) were randomly allocated into two groups. In group I (seven patients), PNF was applied by the therapist, facilitating the functional activities of rolling, sitting and standing, walking and climbing and descending stairs. In group II (seven patients), PNF was self-administered using an elastic tube, and the same activities were facilitated. Experiments were conducted for 1h twice per week for 12 weeks. Low-back pain, a modified Ashworth scale, the functional independence measure (FIM) and the timed up and go test (TUG) were assessed before and after the interventions. Results: In the within-group evaluation, low-back pain was significantly reduced in both groups, the FIM improved in group II, and the results of the TUG improved in group I. In the inter-group analysis, only the tone was lower in group II than in group I. Conclusions: Both PNF protocols were effective in treating patients with HAM/TSP. .