Cervical dystonia: about familial and sporadic cases in 88 patients / Distonia cervical: consideracoes sobre casos esporadicos e familiares em 88 pacientes

Cervical dystonia (CD) affects the musculature of the neck in a focal way or associated to other parts of the body. The aim of this study was to identify clinical differences between patients with dystonia patients without family history and with family history (sporadic). Eighty-eight patients with CD were recruited in a Movement Disorders Clinic between June of 2008 and June of 2009. Only patients with no etiological diagnosis were accepted for analysis. The age of onset of symptoms was later in patients with focal and segmental dystonia than in patients with generalized dystonia (p<0.001). The severity of symptoms was higher in patients with sporadic dystonia than in familial patients (p<0.01). Generalized cases were more severe in patients with a family history (p<0.01). Sporadic patients had higher levels of pain than familial cases (p<0.05). We expect soon to present the results of genetic analyzes of these patients.

A distonia cervical (CD) afeta a musculatura do pescoço de modo focal ou em combinação com outras partes do corpo. O objetivo deste estudo foi identificar diferenças clínicas entre pacientes com distonia com história familiar e pacientes sem história familiar (esporádicos). Foram selecionados 88 pacientes com DC no Setor de Distúrbios do Movimento entre julho de 2008 e junho de 2009. Somente os pacientes sem diagnóstico etiológico foram admitidos para análise. A idade de início dos sintomas foi mais tardia em pacientes com distonia focal e segmentar do que em pacientes com distonia generalizada (p<0,001). A gravidade dos sintomas foi maior em pacientes com distonia focal esporádicos do que naqueles com história familiar (p<0,01). Os casos generalizados foram mais graves nos pacientes com história familiar (p<0,01). Pacientes esporádicos tiveram níveis maiores de dor em relação aos casos familiares (p<0,05). Esperamos apresentar em breve resultados de análises genéticas desses pacientes.

Temporomandibular disorders in patients with craniocervical dystonia / Disfunção temporomandibular em pacientes com distonia craniocervical

Temporomandibular disorders are a set of musculoskeletal dysfunctions within the masticatory system, with multiple etiologies. OBJECTIVE: Since craniocervical dystonia can involve the same neuromuscular structure as the temporomandibular joint, we sought to assess the correlation between temporomandibular disorders and craniocervical dystonia. METHOD: We applied the Research Diagnostic Criteria for Temporomandibular Disorders to 42 patients with craniocervical dystonia, in order to identify orofacial pain and temporomandibular characteristics on the day of botulinum toxin injection. RESULTS: Twenty-two patients (52.3 percent) reported temporomandibular joint pain; 24 (57.1 percent), joint sounds; 20 (47.6 percent), masticatory muscle pain; and 21 (50 percent), diminished jaw mobility. The patients with oromandibular dystonia presented temporomandibular disorders more frequently than did patients with other types of craniocervical dystonia (p<0.001). CONCLUSION: Temporomandibular disorders occur frequently in patients with oromandibular dystonia. Further studies should address the proper treatment of temporomandibular disorders associated with dystonia.

As disfunções temporomandibulares são um conjunto de alterações musculoesqueléticas no sistema mastigatório de etiologia multifatorial. OBJETIVO: A distonia craniocervical pode envolver as mesmas estruturas neuromusculares da articulação temporomandibular. Nosso objetivo foi avaliar a correlação entre distúrbios temporomandibulares e distonia craniocervical. MÉTODO: Aplicamos o Critério Diagnóstico para Pesquisa em Disfunção Temporomandibular em 42 pacientes com distonia craniocervical a fim de identificar dor orofacial e características da articulação temporomandibular no dia da injeção de toxina botulínica. RESULTADOS: Vinte e dois pacientes (52,3 por cento) relataram dor na articulação temporomandibular, enquanto 24 apresentaram sons articulares (57,1 por cento), 20 dor na musculatura mastigatória (47,6 por cento) e redução da mobilidade mandibular foi observada em 21 pacientes (50 por cento). Os pacientes com distonia oromandibular apresentaram disfunção temporomandibular em maior frequência do que aqueles com outros tipos de distonia craniocervical (p<0,001). CONCLUSÃO: A disfunção temporomandibular é frequente em pacientes com distonia oromandibular. Novos estudos devem abordar o tratamento adequado das disfunções temporomandibulares associado à distonia.

Manejo con onabotulinumtoxin A del dolor y distonía focal en paciente tetrapléjico pediátrico / Pain and focal dystonia in a pediatric quadriplegic patient: management with onabotulinumtoxin A: a case report

Introduction: Focal dystonia can cause pain and interfere with rehabilitation goals and affect quality of life and family, in a pediatric patient with recent organic brain damage. Objective: This study examined the effects of onabotulinumtoxin A on focal dystonia, posture malalignment, and pain during the sub-acute phase. Method: At four mounths of progress, a 10 years old girl, with mixed quadriparesis secondary to tuberculous meningoencephalitis is presented. The patient was semi-conscious, malnourished, gastrostomized, and exhibited pain at upper right limb mobilization. Physical exam evidenced abnormal scapular posture, and fixed cephalic rotation. Initial treatmnt consisted of neurodevelopmental techniques added to oral antiespatic medication, with no clinical results. Subsequent treatment consisted of onabotulinumtoxin A infiltration, guide with electromyographic technique to those muscles that showed greater dystonic activity, mapped during previous evaluations. Pain was measured according to the Visual Pediatric Analogue Scale, and passive axial alignment and spasticity according to a modified version of the Ashworth Scale, pre and post treatment. Results: Two weeks after infiltration, the patient showed an objective decrease in pain during mobilization, and achieved aligned axial posture both while standing and sitting. At three months follows-up, patient maintained a decline in the dystonic pattern, which allowed adequate positioning to enable the integration of both upper limbs during activities, without pain interference. Discussion: The use of onabotulinumtoxin A could play a role in the management of focal dystonia and a secondary pain, during the sub-acute phase of organic brain damage.

Introducción: En un paciente pediátrico con daño orgánico cerebral reciente, la distonía focal puede ser causa de dolor que interfiera con los objetivos de rehabilitación y repercuta en la calidad de vida del paciente y su familia. Objetivo: Mostrar el efecto de la onabotulinumtoxin A sobre cuadro de distonía focal, con alteración postural y dolor en pacientes en etapa subaguda. Método: Presentamos a una niña de 10 años, portadora de tetraplejia mixta secundaria a meningoencefalitis tuberculosa, estado de mínima conciencia, desnutrición, gastrostomizada, de cuatro meses de evolución, quien presentaba dolor a la movilización de la extremidad superior derecha y al examen físico; se encontró compromiso postural de escápula y giro mantenido cefálico. Se inició manejo con técnicas de neurodesarrollo y antiespásticos orales sin respuesta clínica. Se efectuó infiltración de onabotulinumtoxin A con técnica de guía electromiográfica en los músculos que presentaron mayor descarga distónica mapeados en evaluación previa. Se objetivó el dolor según Escala visual análoga pediátrica, alineamiento pasivo axial y espasticidad según Escala modificada de Ashworth, pre y post procedimiento. Resultados: Tras dos semanas post infiltración, se objetivó paciente con disminución del dolor frente a la movilización, con postura alineada axial tanto en decúbito como sedente. A los tres meses mantenía disminución en hipertonía, posicionamiento adecuado que permitía actividades de integración de ambas extremidades superiores sin interferencia por dolor. Discusión: El uso de onabotulinumtoxin A puede cumplir función en el control de la hipertonía y en el control del dolor secundario, en un paciente de evolución subaguda posterior a daño cerebral adquirido.