Specific versus non-specific exercises for the neck extensor muscles in women with chronic idiopathic neck pain: A randomized controlled trial.

BACKGROUND: Structural and functional impairments of the cervical extensor muscles have been demonstrated in people with neck pain. A global exercise approach targeting all neck extensor muscles has shown positive effects in this population. However, to date, the efficacy of exercises specifically targeting the deep neck extensors has neither been tested nor compared to global exercises for the neck extensors. OBJECTIVES: To compare the effects on pain and disability of a specific lower deep neck extensors (SLDNE) versus a general neck extensor (GNE) exercise program in women with chronic idiopathic neck pain. METHODS: Fourty-three women with chronic idiopathic neck pain were randomly allocated to either a six-week SLDNE or a GNE exercise program. As primary outcome, neck disability was measured with the Neck Disability Index (NDI). Secondarily, pain intensity (VAS), cervical ROM, pressure pain thresholds (PPTs), cervical and thoracic posture and self-perceived benefit of treatment (GROC) were also measured. Every outcome was measured at baseline and immediately after treatment, except NDI, which was also measured at 6-months follow-up. The GROC was only assessed post-intervention. RESULTS: Both exercise programs lead to reduced neck disability immediately post-intervention (within-group mean difference [MD] = -6.09; 95% Confidence Interval [CI]: 7.75, -4.42 and -4.73; 95%CI: 6.57, -2.91 respectively) and at the 6-months follow-up (-4.47; 95%CI: 6.41, -2.53 and -4.74; 95%CI: 6.50, -2.97), but with no between group differences. Similar results were found for pain intensity post-intervention, with no between group interaction (within-group MD = -20.87 mm; 95% CI: 28.55, -13.19 and -18.00 mm; 95%CI: (-26.24, -9.76) for SLDNE and GNE groups, respectively). GROC improved after both interventions without any between-group difference. CONCLUSIONS: A six-week exercise program specifically targeting the lower deep neck extensors lead to comparable outcomes as a general neck extensor exercise program in women with chronic idiopathic neck pain.

Miastenia gravis seronegativa asociada a otras enfermedades autoinmunes / Seronegative myasthenia gravis associated with other autoinmune diseases

Introducción. La presencia de anticuerpos contra el receptor tirosincinasa muscular específica (MuSK) define un subgrupo de pacientes con miastenia gravis generalizada que por su distribución clínica y negatividad de los anticuerpos contra el receptor de la acetilcolina (anti-AchR) su diagnóstico es más complicado, especialmente cuando se asocia a otras enfermedades autoinmunes. Caso clínico. Mujer de 41 años con clínica de 3 meses de evolución consistente en diplopía, disartria e inestabilidad de la marcha. A la exploración se observó sólo una leve paresia del recto externo derecho sin fatigabilidad. Las pruebas complementarias efectuadas fueron normales, incluyendo potenciales evocados multimodales, excepto la resonancia magnética cerebral, donde se detectaron seisocho lesiones hiperintensas nodulares periventriculares y en ambos centros semiovales, con afectación de la corona radiada y el cuerpo calloso sin captación de contraste. Ante estos hallazgos se diagnosticó enfermedad desmielinizante, recibiendo tratamiento con megadosis de metilprednisolona durante 5 días, con discreta mejoría clínica. Al mes empeoró, presentando disfagia e insuficiencia respiratoria, ampliando el estudio neurofisiológico, detectando Jitter muy patológico en el músculo frontal. A pesar de los anticuerpos anti-AchR negativos se inició tratamiento con bromuro de piridostigmina con mala respuesta, precisando incluso ingreso en la unidad de cuidados intensivos y plasmaféresis por nueva crisis respiratoria. La evolución tórpida y el resultado positivo de los anticuerpos MuSK han confirmado el diagnóstico. Conclusión. La detección de estos anticuerpos y la realización de pruebas neurofisiológicas en músculos clínicamente deficitarios son necesarias para el diagnóstico de estas formas clínicas, especialmente cuando los hallazgos patológicos mediante neuroimagen no justifiquen la evolución clínica del paciente (AU)

Introduction. The presence of muscle-specific receptor tyrosine kinase (MuSK) defines a subset of patients with generalized myasthenia gravis. The diagnosis of this disease, due to its clinical distribution and negativity of the acetylcholine receptor (AchR) antibodies, is mo re complicated, especially when linked to other autoimmune diseases. Case report. A 41 year woman with 3 month long symptoms consisting in diplopia, dysarthria and gait instability. On examination, only mild paresis of the right external rectus without fatigability. The complementary tests performed were evoked potentials were normal including multimodal except for the brain magnetic resonance imaging that detected seix-eight hyperintense periventricular nodular lesions in both semioval centers, with impairment of corona radiata and corpus callosum wi thout contrast uptake. Given these findings, she was diagnosed of demyelinating disease and treated with megadoses of methylprednisolone for 5 days with mild clinical improvement. At one month, her condition deteriorated, presenting dysphagia and respiratory failure. The neurophysiological study was extended, and very pathological Jitter was detected in the frontal muscle. Despite the negative AchR antibodies, treatment was initiated with pyridostigmine bromide with poor response, admission to the intensive care unit and plasmaphe resis due to a new respiratory episode being required. The torpid course and positive outcome of the MuSK antibodies have confirmed the diagnosis. Conclusions. The detection of these antibodies and performance of neurophysiological tests in clinically deficient muscles are required for the diagnosis of these clinical forms, especially when the neuroimaging-based pathological findings do not justify the clinical course of the patient (AU)

[Methods for diagnosing seronegative myasthenia gravis]. / Métodos diagnósticos de la miastenia grave seronegativa.

INTRODUCTION: A peculiar feature of seronegative myasthenia gravis is that it presents negative acetylcholine-receptor antibodies; determination of muscle-specific receptor tyrosine kinase (MuSK) antibodies defines a subgroup of patients with generalised myasthenia gravis with certain clinical and neurophysiological peculiarities. DEVELOPMENT: Its diagnosis requires the presence of weakness with fatigability, determination of positive anti-MuSK antibodies and alterations in neurophysiological testing of the neuromuscular junction. It is usually more serious and has a poorer prognosis than the seropositive forms, develops in an acute or subacute manner, and the neurological deficit predominates in the facial, bulbar and respiratory muscles. CONCLUSIONS: Titration of the anti-MuSK antibodies and conducting neurophysiological tests, especially jitter assessment using single-fibre electromyography in clinically deficient muscles, are not only necessary for an early diagnosis of these clinical forms, but also so as to be able to carry out an objective evaluation of the clinical progression and response to treatment.

Métodos diagnósticos de la miastenia grave seronegativa / Methods for diagnosing seronegative myasthenia gravis

La miastenia grave generalizada seronegativa tiene la peculiaridad de presentar anticuerpos contrael receptor de la acetilcolina negativos; sin embargo, la determinación de anticuerpos contra el receptor de tirosincinasa muscular específica (MuSK) define un subgrupo de pacientes con miastenia grave generalizada con peculiaridades desde un punto de vista clínico y neurofisiológico. Desarrollo. Para su diagnóstico, es necesaria la presencia de debilidad con fatiga,determinación de anticuerpos anti-MuSK positivos y pruebas neurofisiológicas de placa neuromuscular alteradas. Suele ser clínicamente más grave y con peor pronóstico que las formas seropositivas, cursa de forma aguda o subaguda y el déficit neurológicopredomina en la musculatura facial, bulbar y respiratoria. Conclusión. La titulación de los anticuerpos anti-MuSK y la realización de pruebas neurofisiológicas, especialmente la valoración del jitter con electromiografía de fibra simple enmúsculos clínicamente deficitarios, no sólo son necesarias para el diagnóstico precoz de estas formas clínicas, sino también para valorar de forma objetiva la evolución clínica y la respuesta al tratamiento

A peculiar feature of seronegative myasthenia gravis is that it presents negative acetylcholine-receptorantibodies; determination of muscle-specific receptor tyrosine kinase (MuSK) antibodies defines a subgroup of patients with generalised myasthenia gravis with certain clinical and neurophysiological peculiarities. Development. Its diagnosis requires the presence of weakness with fatigability, determination of positive anti-MuSK antibodies and alterations in neurophysiological testing of the neuromuscular junction. It is usually more serious and has a poorer prognosis than the seropositive forms, develops in an acute or subacute manner, and the neurological deficit predominates in the facial, bulbar and respiratory muscles. Conclusions. Titration of the anti-MuSK antibodies and conducting neurophysiological tests, especially jitter assessment using single-fibre electromyography in clinically deficient muscles, are not only necessary for an early diagnosis of these clinical forms, but also so as to be able to carry out an objective evaluation of the clinical progression and response to treatment

[Zonisamide and neuropathic pain]. / Zonisamida y dolor neuropático.

INTRODUCTION: In neuropathic pain, as occurs in epilepsy, researchers are striving to find a drug capable of inhibiting the pain-generating ectopic discharges that are produced as a result of neuronal hyperexcitability. This is mediated by ionic exchanges across the channels of the synaptic membrane. This is why the drugs that act on the different types of channels involved in this transmission can regulate neuronal hyperexcitability and therefore have an effect on the pain. DEVELOPMENT: In recent years researchers have gained a deeper understanding of the mechanisms of action of antiepileptic drugs and, since the discovery of their action on one or several synaptic channels, the use of these agents to treat neuropathic pain has become increasingly common. Patients suffering from central pain are also beginning to benefit from the administration of these drugs, especially agents that have proved to be capable of acting with several mechanisms of action and on several channels at the same time. In addition, fewer and less severe side effects are produced, something that is fundamental if we bear in mind the characteristics of patients with central pain, most of whom are adults and elderly. This, together with the fact that there are fewer interactions with other drugs, has led to the new antiepileptic drugs' becoming the preferred medication for this pathology today. CONCLUSIONS: Zonisamide acts on several types of channels and it is known to have four different mechanisms of action, which means it can be effective in treating these patients, although further studies are required (above all randomised double-blind trials) in order to really evaluate the usefulness of these drugs in the treatment of neuropathic pain.

Zonisamida y dolor neuropático / Zonisamide and neuropathic pain

Como ocurre en la epilepsia, en el dolor neuropático se busca un fármaco capaz de inhibir las descargasectópicas generadoras del dolor que se producen a causa de una hiperexcitabilidad neuronal. Ésta se encuentra mediada por el intercambio iónico a través de los canales de la membrana sináptica. Por esta razón, los fármacos que actúen sobre los diferentes tipos de canales involucrados en dicha transmisión pueden regular la hiperexcitabilidad neuronal y, por tanto,actuar frente al dolor. Desarrollo. En los últimos años, tras tener un mejor conocimiento de los mecanismos de acción de los antiepilépticos y al descubrirse su acción sobre uno o varios canales sinápticos, su uso en dolor neuropático se ha ido extendiendo.El dolor central comienza ahora a beneficiarse del uso de estos fármacos, sobre todo de aquellos que han demostrado ser capaces de actuar con varios mecanismos de acción y sobre varios canales al mismo tiempo. Todo ello unido a la aparición de menos efectos adversos y de menor gravedad, hecho fundamental al tener en cuenta la naturaleza de los pacientes con dolor central, la mayoría adultos y ancianos, junto con el menor número de interacciones con otros fármacos, hace que los nuevos antiepilépticos sean en este momento los fármacos de elección en esta patología. Conclusión. La zonisamidaactúa sobre varios tipos de canales y se le conocen cuatro mecanismos de acción diferentes, por lo que puede ser eficaz en el tratamiento de estos pacientes, aunque se precisan estudios más extensos, sobre todo aleatorizados doble ciego, para evaluarrealmente la utilidad de estos fármacos en el tratamiento del dolor neuropático

In neuropathic pain, as occurs in epilepsy, researchers are striving to find a drug capable of inhibitingthe pain-generating ectopic discharges that are produced as a result of neuronal hyperexcitability. This is mediated by ionic exchanges across the channels of the synaptic membrane. This is why the drugs that act on the different types of channels involved in this transmission can regulate neuronal hyperexcitability and therefore have an effect on the pain. Development.In recent years researchers have gained a deeper understanding of the mechanisms of action of antiepileptic drugs and, since the discovery of their action on one or several synaptic channels, the use of these agents to treat neuropathic pain has becomeincreasingly common. Patients suffering from central pain are also beginning to benefit from the administration of these drugs, especially agents that have proved to be capable of acting with several mechanisms of action and on several channels at thesame time. In addition, fewer and less severe side effects are produced, something that is fundamental if we bear in mind the characteristics of patients with central pain, most of whom are adults and elderly. This, together with the fact that there are fewer interactions with other drugs, has led to the new antiepileptic drugs’ becoming the preferred medication for thispathology today. Conclusions. Zonisamide acts on several types of channels and it is known to have four different mechanisms of action, which means it can be effective in treating these patients, although further studies are required (above all randomised double-blind trials) in order to really evaluate the usefulness of these drugs in the treatment of neuropathic pain

Síndrome de Guillain-Barré que simula un ictus vertebrobasilar / Guillain-Barre syndrome mimicking a vertebrobasilar stroke

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