Trigeminal Neuralgia (Tic Douloureux) - Peripheral Nerve Pathologies
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Questions and Answers

What is the age range when Trigeminal Neuralgia usually occurs?

  • 30-50
  • 70-90
  • 50-70 (correct)
  • 20-40

    • Which of the following is NOT a characteristic of Trigeminal Neuralgia?

  • No structural damage to the neurons
  • Bilateral (correct)
  • Unilateral
  • Affects both motor and sensory functions

    • Which division of the trigeminal nerve is less commonly affected in Trigeminal Neuralgia?

  • Mandibular
  • Frontal
  • Maxillary
  • Ophthalmic (correct)

    • What is the name of the muscle that the trigeminal nerve supplies motor function to?

    <p>Muscles of mastication</p> Signup and view all the answers

    What is the duration of each bout of pain in Trigeminal Neuralgia?

    <p>Several seconds to minutes</p> Signup and view all the answers

    In which condition may Trigeminal Neuralgia be an early sign?

    <p>Multiple Sclerosis</p> Signup and view all the answers

    What is the name of the part of the brain where the trigeminal nerve exits?

    <p>Pons</p> Signup and view all the answers

    What is the gender that is more affected by Trigeminal Neuralgia?

    <p>Females</p> Signup and view all the answers

    What is the primary consideration when testing for trigeminal neuralgia?

    <p>Avoiding the trigger zone</p> Signup and view all the answers

    Why may a client with trigeminal neuralgia be referred to an MD?

    <p>To rule out tumours or infection</p> Signup and view all the answers

    What is the recommended position for a client with trigeminal neuralgia during massage therapy?

    <p>Supine or side-lying on the unaffected side</p> Signup and view all the answers

    What is a contraindication for massage therapy in clients with trigeminal neuralgia?

    <p>Massaging during an attack</p> Signup and view all the answers

    What is the goal of massage therapy for clients with trigeminal neuralgia?

    <p>To provide relief from pain and anxiety</p> Signup and view all the answers

    What is a common medication used to treat trigeminal neuralgia?

    <p>Carbamazepine</p> Signup and view all the answers

    What is a possible surgical approach for treating trigeminal neuralgia?

    <p>Separating the compressing artery or vein from the nerve</p> Signup and view all the answers

    What is a possible outcome of severe trigeminal neuralgia treatment?

    <p>Permanent numbness of the affected side of the face</p> Signup and view all the answers

    Why is it important to consider other conditions that may mimic trigeminal neuralgia during assessment?

    <p>To rule out other conditions that may require different treatment</p> Signup and view all the answers

    What is an important consideration when providing massage therapy for clients with trigeminal neuralgia resulting from pathologies such as MS or RA?

    <p>Modifying techniques and positioning according to the underlying condition</p> Signup and view all the answers

    What are the three divisions of the Trigeminal Nerve?

    <p>Ophthalmic, Maxillary and Mandibular</p> Signup and view all the answers

    Which muscle is responsible for tensor tympani?

    <p>Tensor tympani muscle</p> Signup and view all the answers

    What is the most common location of the trigger zone in Trigeminal Neuralgia?

    <p>All of the above</p> Signup and view all the answers

    What is a common cause of Trigeminal Neuralgia?

    <p>All of the above</p> Signup and view all the answers

    What is the recommended position for a person with Trigeminal Neuralgia during massage therapy?

    <p>Supine position</p> Signup and view all the answers

    What is the duration of pain in Trigeminal Neuralgia?

    <p>15-30 seconds</p> Signup and view all the answers

    What is a secondary symptom of Trigeminal Neuralgia?

    <p>All of the above</p> Signup and view all the answers

    What is the impact of Trigeminal Neuralgia on daily activities?

    <p>Unable to perform ADLs during attacks</p> Signup and view all the answers

    What is a common description of the pain in Trigeminal Neuralgia?

    <p>Sharp, electrical, and stabbing</p> Signup and view all the answers

    What is the importance of assessment in Trigeminal Neuralgia?

    <p>All of the above</p> Signup and view all the answers

    Which cranial nerve is affected in Bell's palsy?

    <p>Cranial nerve #7</p> Signup and view all the answers

    What is the most common neurological condition affecting how many people each year?

    <p>25 in 100,000</p> Signup and view all the answers

    What is the duration of the abrupt rapid onset of Bell's palsy?

    <p>48 hours</p> Signup and view all the answers

    Which muscle is NOT supplied by the facial nerve?

    <p>Levator Palpebrae Superioris</p> Signup and view all the answers

    Where does the facial nerve pass through?

    <p>Osseous petrous canal of the temporal bone</p> Signup and view all the answers

    What is the prognosis of Bell's palsy that results from complete compression?

    <p>Poorer</p> Signup and view all the answers

    What percentage of Bell's palsy cases recover spontaneously?

    <p>70%</p> Signup and view all the answers

    Through which foramen does the facial nerve exit?

    <p>Stylomastoid foramen</p> Signup and view all the answers

    What is the direction of pressure applied during facial massage for clients with facial paralysis?

    <p>From the lateral side towards the midline</p> Signup and view all the answers

    Why is it important to keep the affected eye covered during facial massage?

    <p>To prevent infection</p> Signup and view all the answers

    What is the purpose of having the client practice facial exercises during remedial exercise and self-care?

    <p>To regain lost actions</p> Signup and view all the answers

    What is the recommended frequency for using lubricating ointment for clients with facial paralysis?

    <p>At night</p> Signup and view all the answers

    What is a common risk factor for non-recovery of facial paralysis?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of lymphatic drainage for the face and neck during facial massage?

    <p>To remove toxins</p> Signup and view all the answers

    Why is it important to stabilize the head during facial massage for clients with facial paralysis?

    <p>To keep the head well stabilized</p> Signup and view all the answers

    What is the percentage of clients with facial paralysis who recover within 6 months?

    <p>80%</p> Signup and view all the answers

    What muscles are affected in Bell's palsy?

    <p>All of the above</p> Signup and view all the answers

    Which salivary gland is affected in Bell's palsy?

    <p>Submandibular and sublingual salivary glands</p> Signup and view all the answers

    What is a common symptom of Bell's palsy?

    <p>Decreased salivation and drooping of the mouth</p> Signup and view all the answers

    What is a possible cause of Bell's palsy?

    <p>All of the above</p> Signup and view all the answers

    How is the affected eye affected in Bell's palsy?

    <p>It is unable to close fully</p> Signup and view all the answers

    What is the purpose of wearing a patch over the eye in Bell's palsy?

    <p>To protect the eye from injury</p> Signup and view all the answers

    What is a common sign of Bell's palsy?

    <p>Sudden, unilateral palsy to one side of the face</p> Signup and view all the answers

    What is the goal of massage therapy in Bell's palsy?

    <p>To reduce muscle tension and promote motor re-education</p> Signup and view all the answers

    What is an important consideration during assessment of Bell's palsy?

    <p>All of the above</p> Signup and view all the answers

    What is a possible outcome of Bell's palsy?

    <p>All of the above</p> Signup and view all the answers

    What is the compression syndrome of the brachial plexus within the shoulder girdle?

    <p>Thoracic Outlet Syndrome</p> Signup and view all the answers

    Which muscles form the interscalene triangle?

    <p>Anterior and middle scalene muscles</p> Signup and view all the answers

    What space narrows when the shoulder is fully abducted and externally rotated?

    <p>Retropectoralis minor space</p> Signup and view all the answers

    What is the course of the neurovascular bundle?

    <p>Between the anterior and middle scalene muscles</p> Signup and view all the answers

    What is the function of the brachial plexus?

    <p>Innervates the arm</p> Signup and view all the answers

    What is the effect of slouching forward on the costoclavicular space?

    <p>It narrows the space</p> Signup and view all the answers

    What is the effect of taking a deep inhale on the interscalene triangle?

    <p>It elevates the floor of the space</p> Signup and view all the answers

    What is the effect of a tight subclavius muscle on the costoclavicular space?

    <p>It narrows the space</p> Signup and view all the answers

    Which of the following does not involve the subclavian vein in Thoracic Outlet Syndrome?

    <p>an extra cervical rib</p> Signup and view all the answers

    What is the typical presentation of Thoracic Outlet Syndrome?

    <p>Unilateral or bilateral symptoms</p> Signup and view all the answers

    What is a possible symptom of neurological involvement in Thoracic Outlet Syndrome?

    <p>Numbness and/or tingling along the C8-T1 Dermatomes</p> Signup and view all the answers

    Which of the following can cause compression of the neurovascular bundle?

    <p>All of the above</p> Signup and view all the answers

    What is a possible outcome of severe Thoracic Outlet Syndrome?

    <p>Gangrene</p> Signup and view all the answers

    What is a common location of trigger points in Thoracic Outlet Syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is a possible sign of vascular involvement in Thoracic Outlet Syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is a common postural assessment finding in Thoracic Outlet Syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is a possible cause of Thoracic Outlet Syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is a common finding on palpation in Thoracic Outlet Syndrome?

    <p>All of the above</p> Signup and view all the answers

    What is the primary goal of treatment for thoracic outlet syndrome?

    <p>To relieve compression on the brachial plexus</p> Signup and view all the answers

    What is the name of the syndrome that involves compression of the brachial plexus and subclavian artery between the anterior and/or middle scalene?

    <p>Anterior or Middle scalene syndrome</p> Signup and view all the answers

    What is the name of the test used to assess the length of the Pectoralis Minor muscle?

    <p>Pectoralis Minor Length Test</p> Signup and view all the answers

    What is the name of the technique used to retrain apical breathers and reduce stress on the scalenes?

    <p>Diaphragmatic breathing</p> Signup and view all the answers

    What is a contraindication for massage therapy in clients with thoracic outlet syndrome?

    <p>Both A and B</p> Signup and view all the answers

    What is the recommended frequency of treatment for thoracic outlet syndrome?

    <p>2-3 times per week for 1 hour, then 1ce/week/x4 weeks</p> Signup and view all the answers

    What is the purpose of joint play to the cervical spine, sternoclavicular, and GH joints in the treatment of thoracic outlet syndrome?

    <p>To increase range of motion</p> Signup and view all the answers

    What is the name of the test used to assess for compression of the brachial plexus, subclavian artery, and vein between the clavicle and the first rib?

    <p>Costoclavicular test</p> Signup and view all the answers

    What is the name of the technique used to release tension in the Scalenes, Pectoralis Minor, and Subclavius muscles?

    <p>O&amp;I, muscle stripping and trigger point release</p> Signup and view all the answers

    What is the importance of client compliance to self-care and avoidance of aggravating factors in the treatment of thoracic outlet syndrome?

    <p>It is essential</p> Signup and view all the answers

    Study Notes

    Trigeminal Neuralgia (Tic Douloureux)

    • A disorder of the trigeminal nerve producing severe bouts of lancinating pain lasting several seconds to minutes
    • Pain is distributed along one or more of the trigeminal nerve's sensory divisions, most commonly in the maxillary and less often the ophthalmic division
    • The neuralgia is usually unilateral and commonly affects only one branch of the trigeminal nerve, but may affect both maxillary and mandibular divisions in some cases

    Characteristics

    • Bouts of pain may last a few seconds to several seconds, and may be longer
    • Attacks may progress to several attacks a day, lasting days, weeks, months, or longer
    • Some may have periods with no attacks (remission period)
    • The neuralgia usually occurs in people between the ages of 50-70, but may also be seen in younger people with Multiple Sclerosis

    Anatomy

    • The trigeminal nerve is the largest of the cranial nerves and supplies sensory awareness to the face and head, and motor function to the muscles of mastication and the tensor tympani muscle
    • The nerve exits the brainstem from the pons and its sensory information is transmitted back directly to the brainstem to sensory nuclei that are connected to the reticular formation, cerebellum, and thalamus
    • The nerve passes through four foramen in the skull
    • The afferent branches are separated into three divisions: Ophthalmic, Maxillary, and Mandibular

    Signs and Symptoms

    • There are generally no sensory alterations between attacks, but altered sensation to the face may be present during an attack
    • Other symptoms during an attack may include:
      • Spasm and locking of the muscles of mastication
      • Loss of hearing due to temporary paralysis of the tensor tympani muscle
      • Facial "tics" or grimacing in pain (AKA, "tic douloureux")
      • Extreme antalgic expression, screaming, crying, debilitation
      • Tearing of the eye if the ophthalmic division is affected

    Causes

    • The cause is generally uncertain or idiopathic
    • Compression of the artery or vein "strangles" the nerve and damages the myelin sheath surrounding it, causing it to malfunction
    • Contact with the artery or vein may cause malfunction as well
    • Other causes include:
      • Bone spurs at the foramina
      • Tumors (identified with MRI)
      • Multiple sclerosis; demyelination of the nerve followed by scarring (identified with MRI)
      • TMJ imbalances

    Triggers and Trigger Zone

    • Attacks are generally triggered by touching a trigger zone or an activity involving the trigger zone
    • The trigger zone includes the lips, face, or tongue
    • Triggers include:
      • Light touch
      • Chewing
      • Brushing teeth
      • Washing face
      • Sneezing
      • Blowing the nose
      • Talking
      • A breeze
      • Facial movements
      • Sinus infection
      • Tooth or gum infection
      • Stress
      • A combination of triggers

    Assessment Case History

    • General health (TMJ, Multiple sclerosis)
    • Diagnosis by M.D.?
    • Treatment and Results (medication, surgery)
    • Location of pain (Most commonly maxillary or mandibular)
    • Location of Trigger Zone (small area on face, cheek, tongue)
    • Triggers (light touch, chewing, sneezing, washing face, etc.)
    • Quality of pain (often described as the worst pain in the world, sharp, electrical, stabbing, lancinating, burning, hot poker)
    • Duration of pain (usually 15-30 seconds, may last for a minute or two)
    • Symptoms other than pain (facial "tic" or grimace, tearing of the eye, nausea, weight loss, depression, anxiety, and fear of next attack, suicidal tendencies)

    Treatment and Contraindications

    • The therapist must provide a safe treatment, minding all the contraindications and modifications that need to be made for a person with trigeminal neuralgia
    • Client may be positioned in supine and/or side-lying on unaffected side
    • Absolutely no treatment in prone
    • Hydrotherapy may include heat for trigger points, but should not touch the face
    • Massage may include visualizations, deep breathing, and progressive relaxation techniques
    • The trigger zone must be avoided at all times during treatment

    Medical Treatment

    • Medications include painkillers and anti-seizure drugs
    • Carbamazepine (a powerful anti-convulsent) is often the drug of choice, but liver and hematopoietic functions should be monitored
    • If medication does not control the problem, surgery may be performed

    Bell's Palsy

    • Unilateral flaccid paralysis of the muscles of facial expression caused by a lesion of cranial nerve #7/facial nerve
    • Idiopathic in 70% of cases, with spontaneous recovery in 70% of cases
    • Affects 25 in 100,000 people each year
    • Abrupt rapid onset, reaching maximum weakness within 48 hours
    • Most often unilateral, but can present bilaterally in less than 1% of cases
    • Palsy may result from partial compression or complete compression, leading to Wallerian degeneration (poorer prognosis)
    • Can affect taste sensation, lacrimation, and salivary flow depending on lesion location

    Anatomy

    • Facial nerve arises from the pons, passes through the geniculate ganglion, and exits at the stylomastoid foramen
    • Motor division passes through the osseous petrous canal of the temporal bone, where minor swelling can compress the nerve
    • Five branches supply the face, including:
      • Muscles of facial expression (smiling, frowning, etc.)
      • Muscles of the eyes and forehead (except levator palpbrae superioris)
      • Buccinator and muscles of upper lip
      • Muscles of the lower lip and chin
      • Muscles of the cheeks and nose
      • Stapedius muscle of the eardrum
      • Stylohyoid, platysma, and posterior digastric

    Signs and Symptoms

    • Mouth drooping on the affected side
    • Difficulty chewing on the affected side
    • Inability to wrinkle forehead or dilate nostril on the affected side
    • Loss of lacrimation (tears) and salivation
    • Decreased taste on anterior 2/3 of tongue
    • Heightened sensitivity or distortion of sounds
    • Pain, often localized to the mastoid area
    • Sudden, unilateral palsy to one side of the face, which may be complete or partial flaccid paralysis
    • Sagging of the face, deviating to the unaffected side (risk of contracture)
    • Distortion of facial expressions, pulling towards the unaffected side
    • Drooping eyelid, with inability to close the affected eye fully

    Causes

    • Compression from edema (pregnancy, middle ear infection, diabetes, hypertension)
    • Tumour
    • Trauma to face or head (birth trauma, blunt force trauma, stab wound, facial or dental surgery, concussion)
    • Exposure to cold or chilling of the face
    • Infection affecting the parotid gland (mumps)
    • Middle ear infection

    Assessment

    • Case history: general health, pregnancy, onset, pain, doctor visits, diagnoses, lesion completeness, recent injury or surgery, exposure to cold, medications, steroids
    • Testing:
      • Eye closure: inability to close the affected eye, with eyeball rolling upward and inward
      • Eyebrow raising: asymmetrical lifting and less forehead wrinkling on the affected side
      • Smiling: drooping on the affected side and pulling towards the unaffected side
      • Mouth movements: difficulty articulating certain words or sounds

    Treatment

    • Massage techniques:
      • Neck and shoulder massage to reduce muscle tension and trigger points
      • Facial stroking and running vibrations to relax facial muscles
      • Treat unaffected side of the face first, supporting the affected side with a towel roll
      • Pressure applied from the lateral side towards the midline to avoid tractioning on the nerve
      • Light fingertip kneading and tapotement to affected muscles
    • Facial exercises:
      • Practice vowels and consonants (P, B, M, N)
      • Raise eyebrows, smile, show teeth, whistle, and blow
      • Imagine smelling something and scrunching the face
    • Contraindications and precautions:
      • Infection and injury of the eye
      • Keep pressure and drag on flaccid muscles low
      • Stabilize the head with pillows or towel rolls
      • Avoid lying with face in face cradle due to flaccid paralysis

    Remedial Exercise and Self-Care

    • Practice facial exercises to promote recovery
    • Protect the eye with an eye patch or sterile gauze
    • Use artificial tears during the day and lubricating ointment at night
    • Ensure good oral hygiene to prevent food from getting lodged between teeth and cheek on the affected side

    Prognosis

    • Typically, there is an 80% chance of recovery within 6 months
    • Risks of non-recovery include:
      • Age above 55
      • Hypertension
      • Complete facial paralysis
      • Changes in tearing (crocodile tears – excessive tearing when salivary glands are stimulated during eating)

    Thoracic Outlet Syndrome (TOS)

    • A compression syndrome of the brachial plexus within the shoulder girdle
    • Compression of the lower trunk of the brachial plexus (C8-T1), Subclavian artery, and in some cases the Subclavian Vein in the Thoracic Outlet

    Thoracic Outlet Anatomy

    • Extends from the cervical spine to the pectoralis minor muscle
    • Located between the Scalene muscles, clavicle, and first rib
    • Proximally, it is comprised of the interscalene triangle, formed by the anterior scalene muscle, middle scalene muscle, and the first rib
    • The space may narrow due to:
      • Scalene hypertonicity and trigger points
      • Space-occupying structures (e.g., 7th cervical rib)
      • Deep inhalation, which elevates the floor of the interscalene triangle

    Compression Spaces

    • Interscalene triangle: may narrow due to scalene hypertonicity and trigger points
    • Costoclavicular space: formed by the clavicle anteriorly and the first rib posteromedially
      • May narrow due to retraction of the shoulder, inspiration, and slouching forward
    • Retropectoralis minor space: formed by the pectoralis minor muscle, coracoid process, and ribs 2-4
      • May narrow due to shoulder abduction and external rotation, as well as retraction of the shoulder

    Course of the Neurovascular Bundle

    • The brachial plexus is made up of nerve roots from C5-T1, which innervates the arm
    • Travels along with the Subclavian artery between the anterior and middle scalene
    • Joined by the Subclavian Vein, becoming the neurovascular bundle, and travels deep to the clavicle and Pectoralis Minor

    Signs and Symptoms

    • Neurological symptoms:
      • Numbness and/or tingling along the C8-T1 dermatomes
      • Pain in the shoulder, upper limb, chest, neck, and head
      • Muscle weakness and clumsiness in the hand
      • Atrophy of the hypothenar eminence and interossei
    • Vascular symptoms:
      • Pallor in the hand
      • Pain due to ischemia
      • Cyanosis
      • Distal coolness
      • Venous distention
      • Edema, especially upon waking
      • Joint stiffness

    Causes

    • Compression of the neurovascular bundle by:
      • Extra Cervical Rib (structural)
      • Scalene hypertrophy from overuse, scar tissue, or trigger points
      • Anatomically wide insertion of anterior or middle scalene on the first rib
      • Brachial plexus piercing the anterior scalene muscle
      • Structural bony abnormality of the clavicle and/or first rib
      • Pec minor hypertrophy from repetitive use, scar tissue, or trigger points
      • Trauma/Surgery to the neck or shoulder
      • Respiratory pathologies (Asthma, Emphysema, Bronchitis)
      • Edema (Pregnancy, lymphedema)
      • Hyperkyphotic posture

    Assessment

    • Observation:
      • Postural assessment (hyperkyphosis)
      • Anterior head carriage, protracted scapulae, “slouchy shoulders”
      • “Fullness” at supraclavicular fossa
      • Atrophy of intrinsic hand muscles
      • Swelling of the fingers or dorsum of hand
      • Venous distention
      • Skin/nail changes
    • Palpation:
      • Trigger points and tenderness in the scalenes, pec minor, and subclavius
      • Coolness in the affected hand
      • Edema in the dorsum of hand
    • Testing:
      • AF and PR ROM of C-spine and shoulder
      • Myotomes and dermatomes
      • Spurling’s to rule out possible nerve root compression
      • Adson’s, Reverse Adson’s, Costoclavicular, and Wright’s Hyperabduction tests

    Treatment

    • Aims: relieve the compression site, identify and reduce contributors
    • Techniques:
      • Diaphragmatic breathing
      • Fascial techniques to the upper chest, neck, and shoulder
      • O&I, muscle stripping, and trigger point release to the scalenes, pec minor, and subclavius
      • GTO, petrissage to the pectoralis major, SCM, upper trapezius, and posterior cervical paraspinals
      • Rhythmic mobilizations to the scapulothoracic joint
      • Joint play to the cervical spine, sternoclavicular, and GH joints
      • Traction to the C-Spine
      • PR ROM to the C-spine and Glenohumeral Joint
      • Passive stretches to the muscles and joints of the forearm, wrist, and hand
      • Strengthening to the interscapular muscles and grip muscles of the hand
      • Lymphatic drainage to the arm if necessary

    Contraindications and Precautions

    • Refer immediately for medical attention if a thrombosis is suspected
    • Avoid heavy or hot hydrotherapy and scalene stripping if the client has high blood pressure or a history of atherosclerosis
    • Avoid frictions if the client is on anti-inflammatories
    • Avoid trigger point release, deep petrissage, and deep fascial if the client is on analgesics
    • Modify aggressive techniques where muscle, skin, or circulation is fragile

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    Description

    This quiz covers Trigeminal Neuralgia, a disorder of the trigeminal nerve that produces severe, lancinating pain. It's a common and severe neuralgia affecting females more than males.

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