Comparative effects of fascial distortion model with and without neuromuscular inhibition technique on pain, range of motion and quality of life in patients with piriformis syndrome.

PURPOSE: This study aimed to compare the effects of the fascial distortion model (FDM) with and without neuromuscular inhibition technique (NIT) on pain, range of motion and quality of life in patients with piriformis syndrome. METHODS: The study was a randomized controlled trial and 54 participants were randomly allocated by lottery method into two groups. Group A (27 participants) received the FDM with NIT and Group B (27 participants) received the FDM alone. The patients were treated for six weeks, three sessions each week on alternate days. Outcome measurements were taken before the first treatment session and after the last (sixth week) session. Numeric Pain Rating Scale, Sciatica Bothersomeness Index (SBI), and Goniometer were used as outcome measures. SPSS version 25 was used for statistical analysis. RESULTS: Data was normally distributed by the Shapiro-Wilk Test. Statistically significant improvements (p < 0.05) were observed in the FDM with NIT than in FDM alone. Both groups show significant results in all outcome measures with paired sample t-tests (p < 0.05). CONCLUSION: This study concluded that participants with piriformis syndrome show more improvement in the FDM with NIT than the FDM group alone. TRIAL REGISTRATION NUMBER: NCT05404607.

This study provides the evidence-based result of the Fascial Distortion Model in patients with piriformis syndrome.The combined effects of both treatment techniques; Fascial Distortion Model and Neuromuscular Inhibition Technique can provide more effective results for piriformis syndrome.

Tibialis spastic varus foot without tarsal coalition: a case report.

Tibialis spastic varus foot (TSVF) is an uncommon clinical entity primarily associated with tarsal coalition. This case report presents a rare instance of TSVF without tarsal coalition in an 8­year-old male patient. Successful treatment was achieved through a conservative approach involving botulinum toxin injections and a plaster cast, highlighting the potential of nonsurgical interventions for this rare condition.

Effect and mechanism of acupuncture on airway smooth muscle relaxation during acute asthma attack in rats. / é’ˆåˆºæ¾å¼›å“®å–˜æ€¥æ€§å‘ä½œå¤§é¼ æ°”é“å¹³æ»‘è‚Œçš„ä½œç”¨æœºåˆ¶.

OBJECTIVES: To explore the effect and mechanism of acupuncture at "Feishu" (BL 13) and "Dingchuan" (EX-B 1), and "Kongzui" (LU 6) and "Yuji" (LU 10) for relaxing the airway smooth muscle in the rats during acute asthma attack and compare the effect among the two pairs of acupoints and the acupoints combination. METHODS: Forty SD male rats with SPF grade were randomly divided into a blank group, a model group, a pair-point A group (acupuncture at "Feishu" [BL 13] and "Dingchuan" [EX-B 1]), a pair-point B group (acupuncture at "Kongzui" [LU 6] and "Yuji" [LU 10]) and a point combination group (acupuncture at "Feishu" [BL 13] , "Dingchuan" [EX-B 1], "Kongzui" [LU 6] and "Yuji" [LU 10]), with 8 rats in each group. Except the rats in the blank group, the model of acute asthma attack was induced by ovalbumin (OVA) combined with aluminum hydroxide gel in the rest groups. Started on the 15th day of modeling, except in the blank group and the model group, acupuncture was delivered in the other groups, 30 min in each intervention, once daily, for 14 days. In each group, the latent period of asthma inducing was measured; the lung resistance (LR) and dynamic lung compliance (Cdyn) were determined using lung function detector; the levels of endothelin-1 (ET-1), tumor necrosis factor-α (TNF-α), cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) in serum and bronchoalveolar lavage fluid (BALF) were measured by ELISA; with Masson staining and electron microscopy adopted, the morphology and ultrastructure of airway smooth muscle of the rats were observed; the mRNA and protein expressions of ET-1 and beta-2 adrenergic receptor (ß2-AR) were detected by quantitative real-time fluorescence and Western blot, respectively. RESULTS: Compared with the blank group, the latent period of asthma inducing was shortened (P<0.05), RL increased and Cdyn decreased (P<0.05) with the different concentrations of methacholine (0.025 mg/kg, 0.05 mg/kg, 0.1 mg/kg, 0.2 mg/kg) in the model group. In the pair-point A group, the pair-point B group and the point combination group, the latent period of asthma inducing was prolonged (P<0.05), RL decreased and Cdyn increased (P<0.05) with different concentrations of methacholine when compared with those in the model group; and the latent period of asthma inducing in the point combination group was longer than that in the pair-point A group (P<0.05). Compared with the blank group, the levels of ET-1, TNF-α and cGMP in the serum and BALF were elevated (P<0.05), and those of cAMP reduced (P<0.05) in the model group. The levels of ET-1, TNF-α and cGMP in the serum and BALF were reduced (P<0.05), and those of cAMP elevated (P<0.05) in the pair-point A group, the pair-point B group and the point combination group when compared with those in the model group. In the blank group, the lung tissue was normal structurally. In the model group, the collagen fibers were proliferated increasingly, the smooth muscle was thickened, the mitochondria were swollen, and their cristae disrupted and reduced massively. In the pair-point B group, the collagen fibers were proliferated, the smooth muscle was thicker compared with that in the blank group, the mitochondria were mildly swollen and their cristae disrupted partially. In the pair-point A group and the point combination group, the lung tissue changes were obviously alleviated in comparison with the model group, the mitochondria were slightly swollen and their cristae disrupted occasionally. Compared with the blank group, the mRNA and protein expression of ET-1 increased and that of ß2-AR decreased in the lung tissue of the model group (P<0.05). In the pair-point A group, the pair-point B group and the point combination group, the mRNA and protein expression of ET-1 was reduced and that of ß2-AR elevated in the lung tissue when compared with those in the model group (P<0.05). In comparison with the pair-point A group, the mRNA expression of ß2-AR was elevated in the point combination group (P<0.05). When compared with the pair-point B group, the mRNA expression of ß2-AR increased, the protein expression of ET-1 decreased (P<0.05) in the point combination group. CONCLUSIONS: Acupuncture at "Feishu" (BL 13) and "Dingchuan" (EX-B 1), "Kongzui" (LU 6) and "Yuji" (LU 10), two pairs of acupoints relieves the airway smooth muscle spasm in the rats during acute asthma attack, which may be related to inhibiting the mRNA and protein expression of ET-1 to reduce the excretion of ET-1 and TNF-α; while enhancing the mRNA and protein expression of ß2-AR to balance the levels of cAMP and cGMP. The effect is optimal when acupuncture is delivered at two pairs of acupoints simultaneously.

Division of neuromuscular compartments and localization of the center of the intramuscular nerve-dense region in pelvic wall muscles based on Sihler's staining.

The innervation of the pelvic wall muscles is not very clear. This study aimed to reveal the division of neuromuscular compartments and localize the surface position and depth of the center of the intramuscular nerve-dense region (CINDR) of the pelvic wall muscles based on Sihler's staining. Twenty-four adult cadavers were used. To localize the CINDR of the pelvic wall muscles, horizontal (H) and longitudinal (L) reference lines were drawn, and Sihler's staining was used to reveal the intramuscular nerve distribution. The CINDR projection points (P and P' points) behind and in front of the body surface, the positions of the P points projected onto the H and L lines (PH and PL points), and the depth of CINDR were determined by spiral computed tomography scanning. The piriformis and obturator internus muscles can be divided into two and three neuromuscular compartments, respectively. The PH of CINDR of the piriformis muscle was located at 22.61 ± 2.66% of the H line, the PL was at 28.53 ± 6.08% of the L line, and the puncture depth of the piriformis muscle was at 24.64 ± 2.16% of the PP' line. The PH of CINDR of the obturator internus muscle was at 16.49 ± 1.20% of the H line, the PL was at 10.94 ± 1.09% of its L line, and the puncture depth was 6.26 ± 0.38 cm. These findings may guide the design of the compartmentalized transplantation of the pelvic wall muscles and improve the target localization efficiency and efficacy for injecting botulinum toxin A to treat pelvic wall muscle spasm.

Effect of Microdissection of Inferior Thyroid Artery on Post-operative Hypocalcemia in Total Thyroidectomy.

Hypocalcemia is one of the most common complication after bilateral thyroid surgery. Reported rates range from 5 to 35% and 0.5 to 4.4% for transient and permanent hypocalcemia respectively. Various methods have been devised to reduce the post-operative hypocalcemia and range from modification of surgical techniques to use of loops and avoidance of inadverant neck dissections. We conducted a randomised control trial of 50 patients divided into two groups, to evaluate the effect of microdissection and ligation of distal branches of inferior thyroid artery (group B) on incidence of temporary and permanent hypocalcaemia in patients of total thyroidectomy versus its ligation distally close to the thyroid capsule(group A). Postoperative mean total serum calcium levels were lower in group A as compared to group B (9.13 mg/dl vs. 9.33 mg/dl at 24 h; 8.77 vs. 9.10 at 3rd day and 8.58 vs. 8.96 mg/dl on 10 th day) with p > 0.05. The value of ionized serum calcium as recorded on 3rd day was 4.39 mg/dl for group A and 4.72 mg/dl for group B with p value ≤ 0.001 (Table 2). 19 patients in group A required calcium supplementation for 6 months with incidence of transient hypocalcemia at 76% while 11 patients in group B had calcium supplementation for 6 months with incidence of 40% and difference was significant statistically. Microdissection technique is better for preventing the temporary hypocalcemia and hence decreasing the hospital visits of the patient when compared to the ligation of inferior thyroid artery distally close to the thyroid gland. The incidence of permanent hypocalcemia doesn't varies significantly between both techniques.

Co-occurrence of Anti-GAD65 Syndrome, Type 1 Diabetes Mellitus, and Focal Seizures With Impaired Awareness.

Glutamic acid decarboxylase (GAD) is an intracellular enzyme found in the presynaptic end of nerve terminals that functions to synthesize ​​gamma-aminobutyric acid (GABA) via decarboxylation. Autoantibodies to the GAD65 isoform have been found in high levels in neurological disorders including stiff person syndrome (SPS), autoimmune encephalitis, and refractory epilepsy. Low levels of anti-GAD65 have also been noted in type 1 diabetes mellitus. We present the unusual case of a woman with a longstanding history of focal seizures with impaired awareness and type 1 diabetes mellitus who was found to have extremely high titers of anti-GAD65 and clinical presentation suggestive of stiff person syndrome. This case highlights the increasing significance of autoimmune etiologies within neurologic disorders, as well as the importance of maintaining a high index of suspicion for rare anti-GAD65 syndromes. Although uncommon and with an unclear pathophysiology, we discuss the importance of establishing SPS diagnostic criteria to facilitate timely diagnosis and quickly direct patient management towards immunotherapy.

Clinical Experience of Use of Kampo Medicine Shakuyakukanzoto for Muscle Spasms Caused by Tetanus.

Background Tetanus is an infectious disease caused by Clostridium tetani, which produces tetanospasmin. Intensive care using sedatives and muscle relaxants is required for the management of severe tetanus, however, long-term use of those medicines is associated with the occurrence of post-intensive care syndrome (PICS). Shakuyakukanzoto (SKT), which is clinically used for the treatment of pain associated with sudden myospasm widely, is one of Kampo medicines, and some studies showed that they are effective in treating muscle spasms caused by tetanus. The purpose of this study is to evaluate the usefulness of SKT in the management of tetanus patients from the viewpoint of the reduction of sedatives. Methods Patients who were diagnosed with tetanus and were treated in our hospital between January 2006 and December 2022 were included. Patients were divided into two groups, patients treated with SKT and those without SKT, and the background information and clinical courses, especially the reduction of sedatives, were compared between the two groups. Results There were five tetanus patients who were treated with SKT (SKT(+) group) and two tetanus patients without SKT (SKT(-) group), respectively. Intubation and mechanical ventilation were required for the management of generalized seizures in all seven patients, who were admitted to the intensive care unit (ICU). The administration of propofol could be discontinued after an average of 8.6 days (range: 3-22 days) from the initiation of SKT administration. The dosage of propofol was lower in patients who received SKT versus those who did not; midazolam and fentanyl exhibited a similar tendency. The mean durations of ICU and hospital stays for patients treated with or without SKT were almost equal (the mean durations of ICU stay in SKT(+) and SKT(-) groups were 22.6 and 24.0 days, and those of hospital stay in SKT(+) and SKT(-) groups were 35.2 and 36.0 days, respectively). All seven patients were discharged and transferred to another hospital for rehabilitation. Conclusions SKT may be useful in the management of myospasms in patients with tetanus. It may also prevent the occurrence of PICU in patients with tetanus who require intensive care by reducing the use of sedatives and analgesics.

The highest region of muscle spindle abundance should be the optimal target of botulinum toxin A injection to block muscle spasms in rats.

Purpose: The effective relief of muscle spasticity requires prompt solutions in rehabilitation medicine. This study aimed to reveal that the highest region of muscle spindle abundance is the optimal target of botulinum toxin A (BTX-A) injections for relieve muscle spasm. Methods: Sixty adult, male Sprague-Dawley rats with lower limbs spasm caused by stroke after modeling, weighing (200 ± 20) g, were included in this study. The modelrats were divided into four groups: muscle spasm model group (group A), model rats treated with BTX-A injections into the middle of the muscle belly (group B), model rats treated with BTX-A injections into the center of the intramuscular nerve-dense region (INDR) (group C), and model rats treated with BTX-A injection into the center of the highest region of muscle spindle abundance (HRMSA) (group D). Groups B, C, and D were further divided into two subgroups: the 3rd and 6th days after BTX-A injection. The rats in each group were assigned modified Ashworth scale scores (MAS), and the changes in gastrocnemius muscle tone, wet muscle weight, and cross-sectional area of muscle fiber were detected. Results: Muscle spindle abundance was the highest in the upper part of the INDR. Group B experienced no significant changes in MAS, muscle tone, wet muscle weight, or cross-sectional area of the muscle fiber. Conversely, groups C and D experienced a decrease in these indicators. Group C experienced the most significant decrease in wet muscle weight and cross-sectional area of muscle fibers. Group D experienced the most notable decrease in MAS and muscle tone. There were no significant differences in the indicators between the 3rd and 6th days after BTX-A injections in group B and there were significant differences in the improvement in the indicators between the two subgroups in groups C and D, with group D experiencing more notable intersubgroup differences. Conclusion: The efficacy of BTX-A injections into the HRMSA is significantly superior to that of conventional BTX-A injections into the middle of the belly muscle or the INDR in the treatment of muscle spasms. Hence, HRMSA should be the optimal target of BTX-A to relieve muscle spasms.

Stiffening of the gluteal muscle increased the intramuscular stress: An in-silico implication of deep tissue injury.

Objectives: Deep tissue injury is a common form of pressure ulcers in muscle tissues under bony prominences caused by sustained pressure or shear, which has a great impact on patients with restricted mobility such as spinal cord injury. Frequent spasms in spinal cord injury patients featured by muscle stiffening may be one of the factors leading to deep tissue injury. The purpose of this study was to investigate the relationship between the gluteal muscle shear modulus and intramuscular compressive/shear stress/strain. Methods: A semi-3D finite element model of the human buttock was established using COMSOL software and the acquired biomechanical data were analyzed through Pearson correlation and Spearman correlation. Results: Results showed that the compressive stress, strain energy density, and average von Mises stress increased with the increase of the gluteal muscle shear modulus. Conclusion: These results may indicate muscle stiffening caused by muscle spasms could lead to higher deep tissue injury development risk as well as shed light on effective treatments for relieving muscular sclerosis mechanically.

Muscle spasms as presenting feature of Nivelon-Nivelon-Mabile syndrome.

Hedgehog acyltransferase gene (HHAT)-associated Nivelon-Nivelon-Mabile syndrome (NNMS) is a rare genetic disorder of multiple system involvement with microcephaly, central nervous system malformations, skeletal dysplasia, and 46,XY sex reversal. Other variable and inconsistent features reported in this disorder are muscle spasms, facial dysmorphism, prenatal onset growth restriction, microphthalmia, and holoprosencephaly. This is the sixth postnatal reported patient with biallelic variants in HHAT gene, who presented with microcephaly, short stature, muscle hypertrophy, muscle spasms, and facial dysmorphism. The most prominent and presenting finding in this patient were muscle hypertrophy and muscle spasms which had a clinical response to phenytoin and acetazolamide treatment. Our report emphasizes the phenotypic variability of NNMS and further reiterates muscle spasms as an important clinical manifestation of this extremely rare condition.

Effects of an intraoral device (IOD) on electromyographic activity on the masseter and temporal muscles in Class III patients.

OBJECTIVE: Class III malocclusion is characterized by a loss of vertical dimension associated with muscle imbalance. The present study was designed to determine electromyographic amplitude changes in temporal (T) and masseter (M) at rest and during clenching in Class III patients treated with an intraoral device (IOD) over a 24-hour period for 30 days with transcutaneous electrical nerve stimulation (TENS). METHODS: Twelve patients with Class III (mean age 27.7 ± 1.2 years) were treated with TENS and IOD. Ten untreated patients composed the control group. Data were analyzed using Wilcoxon test and ANOVA. RESULTS: Patients treated with TENS and IOD showed a marked decrease in hyperactivity of M and T at rest (p = 0.001) and an increase during clenching (p = 0.001). The control group maintained similar activity in both positions. CONCLUSION: This study confirms that using TENS and IOD in patients improves muscle activity of T and M.

Changes in spasticity following functional electrical stimulation cycling in patients with spinal cord injury: A systematic review.

CONTEXT: Spasticity is one of the most common secondary impairment after spinal cord injury (SCI). It can lead to an increase in the level of disability. The functional electrical stimulation cycling (FES-cycling) promotes recovery in patients with SCI. No systematic review has been published examining the influence of FES-cycling on the spasticity of lower extremities post-SCI.Objective: This review aimed to investigate the effects of the FES-cycling on the lower extremities spasticity in patients with SCI.Methods: PubMed, Scopus, PEDro, REHABDATA, Web of Science, and MEDLINE were searched until December 2019. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.Results: Ten studies were met the inclusion criteria. Two were randomized clinical trials, cohort study (n = 2), and pilot study (n=6). The scores on the PEDro scale ranged from one to nine, with a median score of three. The results showed evidence for the beneficial effects of FES-cycling on the spasticity of lower extremities in individuals with SCI.Conclusion: The FES-cycling intervention may reduce the lower extremities spasticity in patients with various injury levels of SCI. It is not a suitable intervention for medically unstable patients or with contraindication for lower extremities movement. Further randomized controlled trials with a large sample size strongly warranted to confirm our findings.

Rocuronium as Neuromuscular Blockade in Tetanus Patients With Methamphetamine Use Disorder: A Case Report.

BACKGROUND: Spasm control is essential in the management of tetanus. Benzodiazepines are administered as initial treatment of tetanic spasms; however, sedation may be difficult to attain among patients with methamphetamine use disorder. Neuromuscular blocking agents, which act on an entire different mechanism, can be given to induce paralysis. METHODS: We describe 2 cases of patients with methamphetamine use disorder who were diagnosed with severe tetanus and our experience in the use of rocuronium to control their spasms. We performed a systematic review of the SCOPUS and PubMed databases for case reports and case series describing the use of rocuronium in tetanus patients who also have methamphetamine use disorder. We discussed the clinical features and treatment outcomes. RESULTS: A total of 4 cases of patients with substance abuse disorder who had severe tetanus were reported in the literature, including the current cases. The mean age was 28.8 years; all of them male. Trismus, generalized limb and abdominal rigidity were the most common presentation. Three patients underwent emergency tracheostomy. Rocuronium was given as 0.008mg/kg bolus in 1 patient; 2 patients received an intravenous bolus dose of 0.6mg/kg. Infusion dose ranged from 5 to 10 mcg/kg/min. Spasms were controlled within 24-48 hours after giving rocuronium in 3 out of 4 patients. One patient died from complications of dysautonomia and immobility. CONCLUSION: Rocuronium demonstrates a potential role as neuromuscular blocking agent of choice for patients with chronic methamphetamine use disorder and severe tetanus. Management challenges and complications of severe tetanus were also highlighted in this study.

RESUME-1: a Phase III study of tolperisone in the treatment of painful, acute muscle spasms of the back.

Tolperisone is a nonopioid, centrally acting muscle relaxant in clinical development in the USA for the treatment of symptoms associated with acute, painful muscles spasms of the back. CLN-301, RESUME-1, is a 14-day double-blind, randomized, placebo-controlled, parallel-group Phase III study of the efficacy and safety of tolperisone administered orally three-times daily in 1000 male and female subjects at approximately 70 clinical sites in the USA experiencing back pain due to or associated with muscle spasm of acute onset. Tolperisone is a promising therapeutic for managing acute, painful muscle spasms of the back as it appears to lack the off-target CNS effects often seen with conventional skeletal muscle relaxants. Clinical Trials registration number: NCT04671082.

Clonazepam for pain due to muscle spasm in a patient with vertebral compression fractures caused by multiple myeloma: a case report.

BACKGROUND: Vertebral compression fractures can cause severe back pain. Although many types of analgesics and interventional treatments are available, they are sometimes ineffective in mitigating the pain. We encountered a case where clonazepam was effective for the management of severe low back pain caused by lumbar vertebral compression fractures. CASE PRESENTATION: A 44-year-old male was diagnosed with multiple myeloma and had vertebral compression fractures of the first and second lumbar vertebrae. He had been suffering from severe low back pain on movement with muscle spasm and pain-associated anxiety. We considered this breakthrough low back pain to be caused by facet joint pain; thus, we prescribed clonazepam as a muscle relaxant and anxiolytic. Following this treatment, the intractable breakthrough pain was dramatically relieved. CONCLUSION: Clonazepam, which has both muscle relaxant and anxiolytic effects, might be helpful in mitigating pain, associated anxiety, and muscle spasms due to vertebral compression fractures.

Safety of Radiofrequency Ablation of Thoracic T2 and T3 Sympathectomy in Palmar Hyperhidrosis: A Case Report.

INTRODUCTION: Hyperhidrosis is the maladjustment of excess sweating in specific parts of the body. Radiofrequency (RF) therapy has been successfully used to treat hyperhidrosis with a success rate of 85% - 95% in patients refractory to sympathectomy. The main hypothesis was the association between reduced palmar hyperhidrosis and radiofrequency RF therapy. The RF therapy is a less invasive technique, including the utilization of electromagnetic energy that is deposited near the nerve tissue. The mechanism of action of continuous RF could be explained by the destruction of afferent nerve fibers on their way from a nociceptive focus to the central nervous system. Pulsed RF was invented to explore this possibility, with the sole purpose of finding a less destructive and equally effective technique for the application of RF to afferent pathways. Herein, we further evaluated whether the procedure was safe without any complications in routine follow-up in palmar hyperhidrosis. CASE PRESENTATION: Herein, we report the case of a male patient with an age of 22 years undergoing thermal RF sympathectomy therapy of thoracic T2 and T3 sympathetic ganglia for the palmar hyperhidrosis of his right hand observed for 3 months. The patient developed a contraction of the flexor involving the small muscles of the right hand with severe pain and congestion 17 days after the procedure without any other complications. The contraction was relieved by a sonar-guided median nerve block at the wrist with two injections of 2 mL lidocaine 2% and 2 mL dexamethasone. CONCLUSIONS: This study has been the first clinical case report complicated by the development of a contraction of the flexor muscles of the right hand with severe pain and congestion. The spasm was gradually relieved by sonar-guided median nerve injection at the level of the wrist and intended to assess the role of RF ablation with a success rate of 85% - 95% in palmar hyperhidrosis.

Intensive Care Management of Severe Tetanus.

Tetanus is caused by an exotoxin, tetanospasmin, produced by Clostridium tetani, an anaerobic gram-positive bacillus.Tetanospasmin prevents the release of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the spinal cord, brainstem motor nuclei, and the brain, producing muscle rigidity and tonic spasms.Trismus (lockjaw), dysphagia, laryngeal spasms, rigidity of limbs and paraspinal muscles, and opisthotonic posture are common.Frequent severe spasms triggered by touch, pain, bright light, or sounds may produce apnea and rhabdomyolysis.Autonomic overactivity occurs in severe tetanus causing labile hypertension, tachycardia, increased secretions, sweating, and urinary retention. Dysautonomia is difficult to manage and is a common cause of mortality; magnesium sulfate infusion is often used.Antibiotics (penicillin or metronidazole) and wound care reduce toxin production and human tetanus immune globulin neutralizes the circulating toxin.Nasogastric tube placement for feeding and medications is needed.Early elective tracheostomy is performed in moderate or severe tetanus to prevent aspiration and laryngeal stridor.Benzodiazepines help reduce rigidity, spasms, and autonomic dysfunction. Large doses of diazepam (0.2-1 mg/kg/h) are administered via nasogastric tube.Neuromuscular blocking agents and mechanical ventilation are used for refractory spasms.Mortality ranges from 5% to 50%. How to cite this article: Karnad DR, Gupta V. Intensive Care Management of Severe Tetanus. Indian J Crit Care Med 2021; 25(Suppl 2):S155-S160.

Tetanus presenting as painful muscle spasms, dysphagia and delirium in an older adult.

While tetanus is now a rare disease in the UK, it remains an important differential diagnosis for trismus and muscle spasms. Even more so in older adults, as this population is less likely to have received full vaccination. Hence, the highest incidence of tetanus in England is seen in older adults. Written informed consent for publication of their clinical details was obtained from the patient proxy.

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.

The Involvement of CaV1.3 Channels in Prolonged Root Reflexes and Its Potential as a Therapeutic Target in Spinal Cord Injury.

Spinal cord injury (SCI) results in not only the loss of voluntary muscle control, but also in the presence of involuntary movement or spasms. These spasms post-SCI involve hyperexcitability in the spinal motor system. Hyperactive motor commands post SCI result from enhanced excitatory postsynaptic potentials (EPSPs) and persistent inward currents in voltage-gated L-type calcium channels (LTCCs), which are reflected in evoked root reflexes with different timings. To further understand the contributions of these cellular mechanisms and to explore the involvement of LTCC subtypes in SCI-induced hyperexcitability, we measured root reflexes with ventral root recordings and motoneuron activities with intracellular recordings in an in vitro preparation using a mouse model of chronic SCI (cSCI). Specifically, we explored the effects of 1-(3-chlorophenethyl)-3-cyclopentylpyrimidine-2,4,6-(1H,3H,5H)-trione (CPT), a selective negative allosteric modulator of CaV1.3 LTCCs. Our results suggest a hyperexcitability in the spinal motor system in these SCI mice. Bath application of CPT displayed slow onset but dose-dependent inhibition of the root reflexes with the strongest effect on LLRs. However, the inhibitory effect of CPT is less potent in cSCI mice than in acute SCI (aSCI) mice, suggesting changes either in composition of CaV1.3 or other cellular mechanisms in cSCI mice. For intracellular recordings, the intrinsic plateau potentials, was observed in more motoneurons in cSCI mice than in aSCI mice. CPT inhibited the plateau potentials and reduced motoneuron firings evoked by intracellular current injection. These results suggest that the LLR is an important target and that CPT has potential in the therapy of SCI-induced muscle spasms.