Managing painful shoulder after neurological injury

Shoulder pain is common after neurological injury and can be disabling, lead to poor functional outcomes and increase care costs. Its cause is multifactoral and several pathologies contribute to the presentation. Astute diagnostic skills and a multidisciplinary approach are required to recognise what is clinically relevant and to implement appropriate stepwise management. In the absence of large clinical trial data, we aim to provide a comprehensive, practical and pragmatic overview of shoulder pain in patients with neurological conditions. We use available evidence to produce a management guideline, taking into account specialty opinions from neurology, rehabilitation medicine, orthopaedics and physiotherapy.

Autonomic dysreflexia in spinal cord injury

Autonomic dysreflexia is a relatively common condition in people who have a spinal cord injury above the level of T6. It is a potentially life-threatening; without timely and effective treatment, it can have deleterious cardiophysiological and systemic consequences. It is therefore imperative for medical professionals to have a clear understanding of its acute management, and be prepared to provide support and education to those caring for at-risk patients. In this paper we provide practical guidance and supporting evidence regarding the management of autonomic dysreflexia in adults with spinal cord injury.

Severe neurological crisis in adult patients with Tyrosinemia type 1

We report six adult patients with Tyrosinaemia type 1 (HT‐1) who presented with recurrent porphyria‐like neurological crises after discontinuation/interruption of 2‐(2‐nitro‐4‐trifluoro‐methylbenzyol)‐1,3 cyclohexanedione (NTBC) treatment. The crises were life‐threatening for some of the patients, with respiratory muscle paralysis requiring ventilatory support, hemodynamic disturbance due to autonomic changes requiring resuscitation, acute progressive ascending motor neuropathy causing profound impairment, recurrent seizures, and neuropathic pain. Our patients’ porphyria‐like presentations were variably misdiagnosed, with delay to diagnosis resulting in more severe recurrent attacks. We report the first series of neurological crises in adult patients with HT‐1. These crises, which may be fatal, can be prevented and treated effectively with neurologist/physician awareness and patient education.

17 Presentation of Capras syndrome in anti-NMDA receptor encephalitis: a neuro-rehabilitation approach

Objectives/Aims

Capgras syndrome is not often seen in neuro-rehabilitation and few case-reports of Capgras syndrome after anti-NMDA receptor encephalitis exist in literature. This case is relevant in light of how the Capgras sydrome and delusional beliefs affected this patient’s discharge planning, engagement with the multi- disciplinary team during rehabilitation and side-effects of pharmacological management. The challenging aspects of the case revolve around the patient’s persecutory beliefs, his delusional misidentifation disorder and its subsequent management.

Methods

The patient is a middle-aged gentleman with a background of relapsing- remitting multiple sclerosis who presented with seizures, headache, rash and intermittent fevers. He was initially treated as infectious meningoencephalitis and his condition deteriorated due to combination of behavioural change and seizures. A MRI-head suggested viral encephalitis but lumbar puncture and serum showed strongly positive for anti-NMDA receptor antibodies, thought potentially secondary to the patient’s disease-modifying drugs for his multiple sclerosis. After step-down from Intensive Care, the patient was noted to have fixed persecutory delusions regarding his wife and children. He believed that his wife and children were imposters and that the hospital and doctors within it were conspiring against him. He was managed initially with risperidone however the dose could not be increased due to the sedating side-effects resulting in an inability to engage with rehabilitation. He was subsequently changed to aripiprazole and escitalopram with the intention to decrease his delusional misidentification disorder. His delusions partially resolved with the patient accepting his children as his own, but not accepting his wife as truly ‘his wife’. The discharge destination represented a difficulty due to concerns that he may become aggressive (physically/verbally) to his wife if he continued to deem her an ‘imposter’. The patient was managed by sidestepping the conflict; he was more accepting of his wife if introduced as a ‘friend who loves him’. The patient was also allowed to drive the narrative rather than forced to deal with his Capgras syndrome. Results: A discharge home with support (including his wife) became feasible as his delusion thawed.

Conclusions

Managing complicated patients like this involves not only pharmacological options but also psychological/psychiatric intervention and employment of non-confrontational techniques to help better engagement with rehabilitation.

Bi-allelic JAM2 Variants Lead to Early-Onset Recessive Primary Familial Brain Calcification

Primary familial brain calcification (PFBC) is a rare neurodegenerative disorder characterized by a combination of neurological, psychiatric, and cognitive decline associated with calcium deposition on brain imaging. To date, mutations in five genes have been linked to PFBC. However, more than 50% of individuals affected by PFBC have no molecular diagnosis. We report four unrelated families presenting with initial learning difficulties and seizures and later psychiatric symptoms, cerebellar ataxia, extrapyramidal signs, and extensive calcifications on brain imaging. Through a combination of homozygosity mapping and exome sequencing, we mapped this phenotype to chromosome 21q21.3 and identified bi-allelic variants in JAM2. JAM2 encodes for the junctional-adhesion-molecule-2, a key tight-junction protein in blood-brain-barrier permeability. We show that JAM2 variants lead to reduction of JAM2 mRNA expression and absence of JAM2 protein in patient’s fibroblasts, consistent with a loss-of-function mechanism. We show that the human phenotype is replicated in the jam2 complete knockout mouse (jam2 KO). Furthermore, neuropathology of jam2 KO mouse showed prominent vacuolation in the cerebral cortex, thalamus, and cerebellum and particularly widespread vacuolation in the midbrain with reactive astrogliosis and neuronal density reduction. The regions of the human brain affected on neuroimaging are similar to the affected brain areas in the myorg PFBC null mouse. Along with JAM3 and OCLN, JAM2 is the third tight-junction gene in which bi-allelic variants are associated with brain calcification, suggesting that defective cell-to-cell adhesion and dysfunction of the movement of solutes through the paracellular spaces in the neurovascular unit is a key mechanism in CNS calcification.

CD8+ encephalitis: a severe but treatable HIV-related acute encephalopathy

Rapidly progressive encephalopathy in an HIV-positive patient presents a major diagnostic and management challenge. CD8+ encephalitis is a severe but treatable form of HIV-related acute encephalopathy, characterised by diffuse perivascular and intraparenchymal CD8+ lymphocytic infiltration. It can occur in patients who are apparently stable on antiretroviral treatment and probably results from viral escape into the central nervous system. Treatment, including high-dose corticosteroids, can give an excellent neurological outcome, even in people with severe encephalopathy and a very poor initial neurological status. We report a woman with CD8+ encephalitis, with a normal CD4 count and undetectable serum viral load, who made a good recovery despite the severity of her presentation.

Dorsal premotor cortex exerts state-dependent causal influences on activity in contralateral primary motor and dorsal premotor cortex

During voluntary action, dorsal premotor cortex (PMd) may exert influences on motor regions in both hemispheres, but such interregional interactions are not well understood. We used transcranial magnetic stimulation (TMS) concurrently with event-related functional magnetic resonance imaging to study such interactions directly. We tested whether causal influences from left PMd upon contralateral (right) motor areas depend on the current state of the motor system, involving regions engaged in a current task. We applied short bursts (360 ms) of high- or low-intensity TMS to left PMd during single isometric left-hand grips or during rest. TMS to left PMd affected activity in contralateral right PMd and primary motor cortex (M1) in a state-dependent manner. During active left-hand grip, high (vs. low)-intensity TMS led to activity increases in contralateral right PMd and M1, whereas activity decreases there due to TMS were observed during no-grip rest. Analyses of condition-dependent functional coupling confirmed topographically specific stronger coupling between left PMd and right PMd (and right M1), when high-intensity TMS was applied to left PMd during left-hand grip. We conclude that left PMd can exert state-dependent interhemispheric influences on contralateral cortical motor areas relevant for a current motor task.

Transcallosal sensorimotor integration: Effects of sensory input on cortical projections to the contralateral hand

OBJECTIVE

Low amplitude vibration of forearm or hand muscles predominantly activates proprioceptive inputs that influence corticospinal projections in a focal manner, increasing output to the stimulated muscle while reducing output to neighbouring muscles. Modulation of contralateral forearm muscles by vibration has also been reported on one occasion. The aim of the current investigation was to investigate the effects of proprioceptive input from a hand muscle on corticospinal excitability, intracortical inhibition (SICI) and interhemispheric inhibition (IHI) targeting the homologous contralateral muscle.

METHODS

Transcranial Magnetic Stimulation (TMS) was delivered to the left cortical hand area of 10 healthy subjects and surface electromyography (EMG) recordings taken from the right First Dorsal Interosseus (FDI) and Abductor Digiti Minimi (ADM). The effect of low amplitude vibration of the left FDI on MEP amplitudes, SICI and IHI targeting the right hand was assessed.

RESULTS

Vibration of the left FDI caused a significant reduction in MEP amplitudes in the homologous right FDI but not in the right ADM. SICI and IHI targeting both muscles were also significantly increased.

CONCLUSIONS

We conclude that proprioceptive input from a hand muscle reduces the corticospinal excitability of the contralateral homologous muscle. The increases in SICI and IHI suggest that at least some of this effect occurs in the cortex ipsilateral to the stimulus and this may be mediated via transcallosal fibres.

SIGNIFICANCE

These results suggest that sensory input can modulate excitability in both motor cortices simultaneously, as well as the relationship between them. Interventions which modulate this transcallosal relationship may become useful in disorders where abnormal IHI is a potential therapeutic target.