Ultrasound-guided dry needling of masticatory muscles in trigeminal neuralgia - A case series of 35 patients

Background

Trigeminal neuralgia (TGN) is considered a sensory neuropathy. However, reports of pain on chewing/speaking suggest a masticatory myofascial involvement.

Objective

To examine the effect of ultrasound-guided dry needling (USGDN), which deactivates myofascial trigger points in masticatory, neck, and facial muscles on TGN symptoms.

Methods

Charts of 35 patients treated for TGN were retrospectively reviewed. Treatment was USGDN alone or combined with trigeminal ganglion/mandibular nerve pulsed radiofrequency (PRF), followed by yoga mudras to stretch masticatory and facial muscles. Patients were followed for 1-8 years. Outcome parameters were reduction of medications with reduction in neuralgic attack frequency and Numeric Rating Scale (NRS) score.

Results

23 patients (65.7%) received USGDN alone, 12 patients (34.3%) received PRF treatment before USGDN. A significant reduction in the mean (SD) NRS (5.7 [1.2] vs 8.8 [1.6]; P < .001) and neuralgic attack frequency (47 [27] vs 118 [70] attacks/day; P < .001) was seen after PRF compared with baseline, respectively. Following USGDN, the mean (SD) NRS further decreased significantly to 1.0 (0.9) (P < .001). USGDN alone produced a similar improvement in the NRS (8.9 [1.5] at baseline reduced to 0.6 [0.7] post-USGDN; P < .001). Patients in both groups reported a cessation in neuralgic attacks after USGDN. Post-USGDN, 18/27 patients completely discontinued medication, with the mean (SD) carbamazepine dose significantly reducing from 716.7 (260.9) mg/day at baseline to 113.0 (250.2) mg/day post-USGDN (P < .001).

Conclusion

Decisive relief of TGN by USGDN suggests neuromyalgia involving masticatory muscles. Prospective, controlled studies could confirm these findings.

Acquired lacrimal fistula: classification and management

PURPOSE

To classify the acquired lacrimal fistulae (ALF) and assess the outcomes following surgical management.

METHODS

Retrospective, interventional study of all patients presenting with ALF over a 3.5-year period was performed. The fistulae were classified based on photographic evidence with respect to their location, size and nature. Primary outcome measures were complete healing of the fistulous opening and resolution of discharge or leakage from it. Secondary outcome measures were resolution of epiphora and patency of the lacrimal drainage system.

RESULTS

84 eyes of 82 patients who had acquired lacrimal fistulae were analysed. The mean duration of the fistulae presence was 10.12 months. The etiology of ALF was spontaneous following lacrimal abscess rupture in 79 eyes and was secondary to incision and drainage in the remaining 5 eyes. Thirty eyes had fistulectomy along with definitive surgery for the associated nasolacrimal duct obstruction (NLDO), 15 eyes underwent definitive surgery without an additional fistulectomy and 4 fistulae healed spontaneously prior to intervention for NLDO. The resolution of ALF did not differ in between those who underwent fistulectomy versus those who did not. The exceptions were 2 chronic large fistulae with cutaneous lining which needed a definite fistulectomy for resolution along with surgery for NLDO.

CONCLUSION

Most of the acquired fistulae heal by themselves irrespective of the nature, size and location and need no additional treatment in the form of fistulectomy. However, this is not true for those that are large and have a cutaneous lining.

A rare case of pemetrexed-induced diffuse punctal and canalicular stenosis: management by coronary balloon puncto-canaliculoplasty

Several chemotherapeutic agents are known to induce lacrimal drainage stenosis and obstruction, resulting in epiphora. Pemetrexed is one such drug and is used in the management of mesotheliomas and non-small cell lung carcinomas. Pemetrexed inhibits folate metabolism at multiple levels. The present case is the second report of pemetrexed induced punctal and canalicular stenosis, but the first to document dacryoendoscopy findings and report balloon puncto-canaliculoplasty as a minimally-invasive treatment option.

Effectiveness of Faradic and Russian currents on plantar flexor muscle spasticity, ankle motor recovery, and functional gait in stroke patients

BACKGROUND AND PURPOSE

Spasticity is a major disabling symptom in patients post stroke. Though studies have demonstrated that electrical stimulation (ES) can reduce spasticity and improve passive ankle range of motion (ROM), not many studies have evaluated the effectiveness of ES on active ankle ROM. The purpose of this study was to determine the effectiveness of Faradic and Russian currents in the reduction of ankle plantar-flexor spasticity and improving motor recovery in patients post stroke.

METHODS

Eighty-three patients (29 females and 54 males; mean age of 57.12 years) were randomly assigned to Group 1 (task-oriented exercises), Group 2 (Faradic current for 10 min and task-oriented exercises), and Group 3 (Russian current for 10 min and task-oriented exercises) for a period of 5 sessions per week for 6 weeks. All patients were assessed for soleus and gastrocnemius muscles spasticity measured by modified modified Ashworth scale; active and passive range ROM measured by goniometer; and functional ambulation measured by modified Emory Functional Ambulation Profile at the time of recruitment to study and after 6 weeks.

RESULTS

Both the types of stimulation and exercises were not associated with improvements in modified Emory Functional Ambulation Profile (p > 0.05). The results showed that all the groups are effective in improving passive ankle ROM (p < 0.05) and reducing soleus and gastrocnemius muscles spasticity (p < 0.05). Though all the groups were effective in improving active ankle ROM, no group was found to be superior to another after treatment CONCLUSION: Adding ES to exercises are associated with low to medium effect sizes (<0.5) in reducing spasticity and improving ankle ROM.

Identification of the components associated with functioning using the international classification of functioning, disability and health comprehensive core set for stroke in Indian stroke survivors

OBJECTIVES

Rehabilitation interventions are expected to ensure best possible recovery and minimize functional disability in stroke survivors. However, not many studies have investigated patterns of recovery and outcomes after stroke in low-income countries. The objective of this study is to identify the biological, psychological, and social components associated with functioning over time in Indian stroke patients using the International Classification of Functioning, Disability and Health (ICF)-based tools and the Functional Independence Measure (FIM).

METHODS

The functioning profile of stroke survivors who received a standard multi-disciplinary rehabilitation was prospectively assessed using the ICF and the FIM at admission (baseline), at 12 & 24 weeks. Descriptive analyses were performed to identify changes in the frequencies of ICF categories and qualifiers from admission to follow-up.

RESULTS

One hundred and twenty-seven participants (mean age of 56 years) with mean FIM score 68 at baseline participated and completed the study. The mean FIM score at follow-up was 108. The numbers and frequency of ICF categories for activities and participation reduced after rehabilitation. More numbers of environmental factors were identified as barriers at follow-up (15 out of 33) compared to baseline. Within the components of Activities and Participation, significant improvement in functioning was found in 43 out of 51 categories.

CONCLUSION

The results show a reduction in frequencies in ICF activities and participation categories corresponding to basic activities of daily living. Categories corresponding to employment and social integration showed little or no improvement.

Effectiveness of hip abductor strengthening on health status, strength, endurance and six minute walk test in participants with medial compartment symptomatic knee osteoarthritis

BACKGROUND AND OBJECTIVES

Decreased activity of hip abductor musculature has been suggested as a contributing factor for the disease progression in participants with symptomatic knee osteoarthritis (OA). In this study, the effectiveness of 6 weeks isolated hip abductor strengthening on WOMAC, 6 minute walk test and hip strength and endurance in participants with symptomatic medial compartment knee OA were studied.

MATERIAL AND METHOD

Thirty persons with medial compartment knee OA were randomized to hip abductor strengthening group (n = 15) and conventional group (n = 15). Both the groups received intervention for 5 times per week for 6 weeks. 6 minute walk test, health status (WOMAC), hip strength (by modified syphgmomanometer) and hip endurance (number of repetitions) were assessed at baseline and post intervention. The dependent variables were analyzed using 2 × 2 ANOVA, with repeated measurement as second factor to determine the effects of the intervention on each outcome variable.

RESULTS

Significant group-by-time interactions were observed for each variable of interest. Post hoc testing revealed that all the outcome measures improved significantly in the hip abductor strengthening group following the 6-week intervention than the control group.

CONCLUSION

The incorporation of hip-strengthening exercises may be considered along with conventional exercises when designing a rehabilitation program for persons with knee OA.

Effect of trunk muscles training using a star excursion balance test grid on strength, endurance and disability in persons with chronic low back pain

BACKGROUND AND OBJECTIVES

Though core muscles strengthening using upper limbs in various positions and lower limbs in lying have been studied previously in patients with chronic low back pain (CLBP), no study has specifically looked in to the effects of a training program that requires prior motor planning in standing (functional position). The objective of this study was to evaluate the effectiveness of star excursion balance test (SEBT) grid training in improving the outcomes in patients with CLBP.

MATERIALS AND METHOD

Sixty patients with mechanical CLBP who fulfilled our criteria were randomized in to two groups; experimental group received physical diagnostic specific interventions, core muscles strengthening and muscles training using the SEBT grid. The participants in control group received stationary cycling instead of SEBT grid training and the other interventions were uniform. The duration of study was 4 weeks. The dependent variables were analyzed using repeated measures 2 × 3 ANOVA.

RESULTS

At the end of study, both the groups showed a significant reduction in disability and improvement in strength and endurance (p< 0.05). Post-hoc analysis showed that SEBT grid training was better than conventional exercises. Follow-up at 16 weeks revealed a statistically insignificant loss in strength and endurance in control group patients. This reduction was not associated with an increase in disability score. The experimental group patients continued showing improvement.

CONCLUSION

The results of our study show that core muscles strengthening using a SEBT grid are more effective than conventional programs. We hypothesize SEBT training to have a significant role in skill learning. We recommend SEBT grid training to be incorporated in the treatment planning of persons with CLBP.

Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: A randomized controlled trial

BACKGROUND

Altered respiratory function has been found to be associated with back pain. Limited chest excursion in subjects with chronic low back pain (CLBP) may be due to co-contraction or bracing of erector spinae and abdominal muscles; their flexed spinal posture; and/or their compromised spinal stability resulting from dysfunctional transversus abdominis.

OBJECTIVE

To check for the effects of thoracic mobilization on respiratory parameters in subjects with chronic non-specific low back pain.

METHODS

Sixty-two subjects (excluding 11 dropouts) with CLBP of age group 30-60 were randomly allocated to two groups. Both groups received individualized treatment for low back pain (LBP) and HEP (home exercise program) regime of breathing exercises. In addition, group 1 received Maitland's Central postero-anterior vertebral pressure for thoracic spine (T1-T8). Total treatment duration was 10 sessions in 2 weeks (5 sessions/week).

RESULTS

Results showed significant improvement in respiratory parameters viz. Forced Vital Capacity (FVC), Sustained Maximal Inspiratory Pressure (SMIP) and Chest Wall Expansion (CWE) and Oswestry Disability Index (ODI) in both groups (p< 0.05) at end of 2 weeks of intervention. However, improvement was significantly more in group 1 (p < 0.05) receiving additional thoracic mobilization.

CONCLUSION

Subjects with non-specific chronic low back pain with or without radiation to lower limbs when treated with thoracic central PA mobilization, in addition to LBP specific treatment and breathing exercises, show an improvement in respiratory parameters and reduction in disability.

Mobilisation of the thoracic spine in the management of spondylolisthesis

INTRODUCTION

Segmental instability due to lumbar spondylolisthesis is a potential cause of chronic low back pain. Hypomobility of the spine results in compensatory segmental hypermobility of the segment above or below restricted segments. Therefore, the aim of the study is to determine the effects of mobilisation of the hypomobile upper thoracic spine along with conventional flexion exercises and stretching of short hip flexors on the degree of slippage and the functions of the persons with lumbar spondylolisthesis.

METHODOLOGY

All patients with spondylolisthesis were randomly assigned into two groups: Group I - Experimental group, treated with mobilisation of the thoracic spine along with the conventional physiotherapy and Group II - Conventional group, treated with conventional stretching, strengthening, and lumbar flexion exercise programme.

RESULTS

The experimental group treated with mobilisation of the thoracic spine shows a significant reduction in the percentage of vertebral slip from pre-treatment to post-treatment measurements.

CONCLUSION

Low back pain due to spondylolisthesis may be benefited by mobilisation of the thoracic spine along with stretching of short hip flexors, piriformis, lumbar flexion range of motion exercises, core strengthening exercises, etc.

Effect of cervical mobilization and ischemic compression therapy on contralateral cervical side flexion and pressure pain threshold in latent upper trapezius trigger points

Studies have shown a clinical relationship between trigger points and joint impairments. However the cause-and effect relationship between muscle and joint dysfunctions in trigger points could not be established. The purpose of this study was to investigate effects of mobilization and ischemic compression therapy on cervical range of motion and pressure pain sensitivity in participants with latent trigger point in the upper trapezius muscle. Ninety asymptomatic participants with upper trapezius latent trigger point were randomized in to 3 groups: mobilization, ischemic compression and a control. The outcomes were measured over a 2 week period. Repeated measures ANOVA showed statistically and clinically significant pre to post improvement in both the interventional groups compared to control (p < 0.05). However the effect sizes between the intervention groups were small (<0.3) revealing minimal clinical detectable difference.

Effect of Transcutaneous Electrical Nerve Stimulation on Plantar Flexor Muscle Spasticity and Walking Speed in Stroke Patients

BACKGROUND AND PURPOSE

Spasticity is a major disabling symptom in patients post stroke. Although studies have demonstrated that transcutaneous electrical nerve stimulation (TENS) can reduce spasticity, the duration of single session TENS is a subject of debate. The purpose of this study was to determine the sustainability of the effects of TENS applied over common peroneal nerve in the reduction of ankle plantar-flexor spasticity and improving gait speed in patients post stroke.

METHODS

Thirty patients (11 women and 19 men) (mean age of 46.46 years) were randomly assigned to group 1 (task oriented exercises), group 2 (TENS for 30 min and task oriented exercises) and group 3 (TENS for 60 min and task oriented exercises) for a period of five sessions per week for 6 weeks. All patients were assessed for ankle plantar-flexor spasticity, passive ankle dorsi-flexion range of motion, clonus and timed up and go test at the time of recruitment to study, at 3 and 6 weeks of therapeutic intervention.

RESULTS

The overall results of the study suggest that there was a decrease in ankle plantar flexor spasticity, ankle clonus and timed up and go score in all the groups. A greater reduction of spasticity was seen in TENS groups (groups 2 and 3) when compared to control. No significant improvement was found in timed up and go test (TUG) scores between groups.

CONCLUSION

Both 30 min and 60 min of application of TENS are effective in reducing spasticity of ankle plantar flexors, improving walking ability and increase the effectiveness of task related training. Based on the effect size, we would recommend a longer duration application for the reduction of spasticity. Copyright © 2015 John Wiley & Sons, Ltd.

Effect of electrical stimulation to long head of biceps in reducing gleno humeral subluxation after stroke

BACKGROUND

Glenohumeral subluxation is the most frequent complication in post stroke hemiplegia and its reduction has been considered an important goal. Though it has been demonstrated that cyclical electrical stimulation of posterior deltoid and supraspinatus muscles can reduce subluxation, the role of biceps has not been given due consideration.

OBJECTIVE

The purpose of this study was to determine whether electrical stimulation to the long head of biceps could more effectively reduce gleno humeral subluxation.

METHODS

24 patients were selected and consecutively assigned to group 1 (electrical stimulation to supraspinatus & posterior deltoid) and group II (electrical stimulation to supraspinatus, posterior deltoid & long head of the biceps) along with routine physiotherapy and occupational therapy for a period of 5 weeks. All patients were assessed for shoulder subluxation, pain and shoulder active abduction range of motion at the time of recruitment to study and after 5 weeks of therapy.

RESULTS

Both the groups showed significant improvement in parameters measured. Tukey's post hoc analysis showed the results were more significant in Group II.

CONCLUSIONS

Electrical stimulation to biceps along with the supraspinatus and posterior deltoid can more effectively reduce shoulder subluxation.

Relationship of hepatic and renal dysfunction with haemorrheological parameters in Plasmodium falciparum malaria

OBJECTIVES

The present study was designed to assess hepatic and renal dysfunction in Plasmodium falciparum malaria, and evaluate if such abnormalities had any bearing with the hemorrheological dysfunction.

METHODS

Sixty consecutive patients of Plasmodium falciparum malaria with hepatic and renal dysfunction (Group A) and twenty consecutive cases of uncomplicated falciparum malaria (Group B) were studied. Patients with past history of alcoholism, jaundice, chronic renal failure, bleeding diathesis or coagulopathy were excluded from the study. Laboratory investigations done were liver and renal function tests, complete blood count and coagulation profile. The data collected was analysed to inter - correlate parameters of hepatic, renal and hemorrheological dysfunction.

RESULTS

In Group A, all had rigor and chill, icterus while 57% had oliguria and hepatomegaly, 37% splenomegaly, with less than 2% having overt bleeding diathesis. On evaluation, in Group A, 57% had acute renal failure, mean value of bilirubin was 13.91 (+/- 12.53) mg/dL, ALT 76.92 (+/- 37.48) IU/ml, AST 135.32 (+/- 97.33) IU/ml, mean PT was 13.03 (+/- 2.22) seconds, mean aPTT was 31.69 +/- 6.76 seconds, FDP by D-dimer was raised in 53% and LDH was raised in 78% respectively. In Group B mean PT was 11.93 (+/- 1.51) seconds, mean APTT was 29.39 +/- 2.89 seconds and FDP by D-dimer was raised in 30% respectively. Thrombocytopenia was seen in 26% cases in Group A and 15% cases in Group B. On analysis, in Group B, there was statistically significant negative correlation of total platelet count with serum AST (p = .010) and serum ALT (p = .036), serum ALP with BT (p = .036), but positively with CT (p = .006) and aPTT (p = .036). In Group A, serum bilirubin was found to have significant negative correlation with haemoglobin (p = .019),positive correlation with aPTT (p = .037), urea (p = .000) and serum creatinine (p = .000), serum ALP Positively with serum urea (p = .025) and serum creatinine (p = .037), serum urea negatively with haemoglobin(p = .015), so also did serum creatinine (p = .025),prothrombin time positively with serum urea(p = 0.037) and serum creatinine (p = 0.013), serum FDP positively with serum urea (p = 0.038) and serum creatinine (p = 0.022), bleeding time positively with serum AST(p = .002).

CONCLUSION

Despite less than 2% of patients in Group A having clinically overt bleeding diathesis, raised FDP (53%), prolonged aPTT (67%), low total platelet count (26%) and anemia (87%) were found in a significant number of patients, suggesting subclinical DIC. Therefore patients with Plasmodium falciparum malaria have high incidence of subclinical haemorrheological disorders which do not amount to overt DIC but adversely affect renal function contributing to acute renal failure.