Neuralgia and Cranial Nerve 5 Treatment (PDF) - VCMT Class 2 Notes

Neuralgia Pathophysiology (Rattray/Ludwig; p756) Neuralgia (‘nerve-pain’) is a type of nerve dysfunction Neuralgia Overview Pain in the distribution of nerves generally in the absence of objective signs/structural damage to nerve Neuralgia can affect any nerve but is common in Trigeminal (...

Neuralgia Pathophysiology (Rattray/Ludwig; p756) Neuralgia (‘nerve-pain’) is a type of nerve dysfunction Neuralgia Overview Pain in the distribution of nerves generally in the absence of objective signs/structural damage to nerve Neuralgia can affect any nerve but is common in Trigeminal (Cranial Nerve 5) Intercostal Appears as sudden attacks of excruciating pain – “lightning like” or often throbbing There is no real tissue damage or injury to the affected nerve There will be a trigger zone, which causes an attack when stimulated. May be caused by: ​ Local compression (such as from neuroma or previous injury) ​ Demyelinating conditions (eg MS) which leads to scar tissue formation Bony callus from previous injury Prolonged exposure to cold The important point Neuralgia produces paroxysmal, intense pain like a knife or electric bolt along distribution of nerve (unilateral) that lasts from seconds to minutes Often clustered Neuralgias have a trigger zone. Trigger Zones ​ Often stimulated by light touch, temperature extremes (especially cold), intense light ​ Sometimes stimulated by movement Precaution Do not stimulate the trigger zone with assessment, manual techniques, or position on table. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy  Intercostal Neuralgia Anatomy VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Pathophysiology (Rattray/Ludwig; p757) Neuralgia (‘nerve-pain’) is a type of nerve dysfunction Neuralgia Overview Pain in the distribution of nerves generally in the absence of objective signs/structural damage to nerve Neuralgia can affect any nerve but is common in Trigeminal (Cranial Nerve 5) Intercostal Appears as sudden attacks of excruciating pain – “lightning like” or often throbbing There is no real tissue damage or injury to the affected nerve There will be a trigger zone, which causes an attack when stimulated. May be caused by: ​ Diabetes Post-herpes zoster (shingles) - reactivation of virus from dorsal root ganglion at a time of immune suppression Intercostal Neuralgia trigger zone ​ Distribution of the affected segment at the spine and laterally along the intercostal space Key sign: ​ Horrible, lightning-like, terrible pain which comes on in fits for little to no reason ​ Shingles - skin eruptions which eventually dry into scabs; pain usually fades with vesicles. Manifestation Unilateral pain in nerve distribution Precaution Do not stimulate the trigger zone with assessment, manual techniques, or position on table. Intercostal Neuralgia is not a condition of nerve degeneration. However, because of the trigger zone, extreme caution must be taken near the affected area. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy History Do you know what triggers it? ​ What type of stimuli? ​ Where? ​ Are there any patterns? Is it predictable to you in any way? ​ Are you able to touch the area without triggering pain? Is it using light touch or deeper pressure? Dr diagnosis (MD or neurologist)? ​ If so, what is the Dx? What is the prognosis? ​ What treatment are you receiving? Onset ​ Since when? Getting better, worse or the same? What is the rate of change? Assessment None If they have a diagnosis, do not touch the trigger zone. Differential None VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Treatment During acute phase and for a sensible time after most-recent attack, avoid treating the affected area & focus on the rest of the body Relaxation focus including diaphragmatic breathing is indicated. Abdominal massage including diaphragm release. Use rib springing for thoracic mobility (unless osteoporosis or bone conditions or active muscle spasm) Only touch the trigger zone (at any time, including long after the most recent attack) if ​ You have asked about what triggers the pain ​ Your touch will not trigger the pain Working around the trigger zone is always the last/lowest priority Start with diaphragm, rib, intercostal and thoracic work that doesn’t touch the trigger zone Intercostal muscle TrPs (if not the trigger zone) Home Care Diaphragmatic breathing Pain-free thoracic mobility (as long as movement you prescribe is not a trigger) VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy  Cranial Nerve 5 (V) (Trigeminal) Anatomy Above we see the distribution zones of the Cranial Nerve 5’s 3 main branches; Ophthalmic (Purple); Maxillary (Blue); Mandibular (Pink). In the lateral view, we see the cutaneous nerves of the cervical plexus in Green and Yellow areas.Each of the Cranial Nerve 5’s main branches divides into several named cutaneous nerves. You don’t need to memorise the names of these branches. Above we see the Cranial Nerve 5’s ophthalmic branch dividing into cutaneous branches after exiting the skull onto the surface of the face at the supraorbital foramen. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Palpation Palpation of the nerve: Come to the midline of the orbit directly in line with the pupil on each side. Place your fingers in line with this point on the eyebrow. Gently compress and release. This is the supraorbital branch. Move superiorly by the length of your index DIP (or so). Gently compress and release. This is the supraorbital branch again. Move back to the eyebrow and medially to the corner of the eyebrow as it slopes down to the nose. Gently compress and release. This is the supratrochlear branch. Go back to the midline of the orbit and move your fingers onto the maxilla. Gently compress and release. This is the infraorbital branch. Now place your fingers on the mental foramen. This is on the mandible usually in line with the 4th or most lateral incisor in the bottom row of teeth. Gently compress and release. This is the mental branch The zygomaticotemporal branch can be palpated just superior to the anterosuperior edge of the pinna. Palpation of affected tissue: Palpation with RROM of masseter, temporalis, lateral pterygoid. Palpation (light touch) of face for sensation (similar to dermatome testing protocol) VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Function Motor function: Mastication Tensor tympani (audition) Tensor veli palitini (deglutition) Sensory function ​ The face, basically. V1 V2 V3 Sensory from Sensory from Sensory from - skin over upper eyelid - mucosa of nose - anterior 2/3 tongue (not taste) - cornea - palate - cheek and its mucosa - lacrimal glands - part of pharynx - lower teeth - upper nasal cavity - upper teeth - skin over mandible and side of - side of nose - upper lip head anterior to ear - forehead - lower eyelid - mucosa of floor of mouth - anterior half of scalp Motor fibres are found only in V3, the mandibular branch. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Pathophysiology - Trigeminal Neuralgia / Tic Douloureux (Painful Tic) (Rattray/Ludwig; p756) Neuralgia (‘nerve-pain’) is a type of nerve dysfunction Neuralgia Overview Pain in the distribution of nerves generally in the absence of objective signs/structural damage to nerve Trigeminal Neuralgia trigger zone ​ Lips, face, tongue Areas innervated by maxillary division (V2) (most common) or sometimes maxillary and mandibular divisions (V3) Key sign: ​ Horrible, lightning-like, terrible pain which comes on in fits for little to no reason Manifestation Unilateral pain in nerve distribution Facial tics Inflammation of sclera or iris, possible glaucoma Loss of hearing due to paralysis of tensor tympani Locked jaw due to paralysis of muscles of mastication VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy History Do you know what triggers it? ​ What type of stimuli? ​ Where? ​ Are there any patterns? Is it predictable to you in any way? Dr diagnosis (MD or neurologist)? ​ If so, what is the Dx? What is the prognosis? ​ What treatment are you receiving? Onset ​ Since when? Getting better, worse or the same? What is the rate of change? Assessment None If they have a diagnosis, do not touch the trigger zone. Differential Acute migraine, cluster headache. Myofascial pain can occur in similar areas, but the quality and onset are often enough to differentiate the two. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Precaution Do not stimulate the trigger zone with assessment, manual techniques, or position on table. Trigeminal Neuralgia is not a condition of nerve degeneration. However, because of the trigger zone, extreme caution must be taken near the affected area. Treatment Avoid treatment over the trigger zone at any time During acute phase and for a sensible time after most-recent attack, avoid treating the affected area & focus on the rest of the body Address muscle spasms & TrP to decrease facial tics Warm face cloth over affected area to reduce tension Promote relaxation however you’d like ​ Full body relaxation including diaphragmatic breathing is indicated. Decrease facial pain with light facial or scalp massage Decrease trigger points in muscles of mastication Decrease tension using warm compress on affected area Home Care Facial exercises seem to help prevent pain – provide for homecare VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy  Cranial Nerve 7 (VII) (Facial) Anatomy Pathway: Pons > internal acoustic meatus > inner ear > stylomastoid foramen > through parotid gland Branches: See above for motor fibres The facial nerve also has general somatic sensory fibres which innervate the skin of the ear canal and the tympanic membrane. Also, it has special sensory fibres which supply taste to the anterior ⅔ of the tongue. Compression sites: Inner ear (intracranial) Parotid gland VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Palpation Palpation of the nerve: Gently palpate or percuss the parotid gland or zygomatic arch Palpation of affected tissue: Assess for flaccidity of muscles around forehead, eye, nose, mouth Boggy edema may be palpated around parotid gland on affected side (edema is more commonly intracranial, however) This image shows the intracranial pathway. It has nothing to do with palpation. It is intended to help understand that the nerve is highly susceptible to compression in such small spaces with any accumulation of fluid/edema. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Function Motor function: Facial expression Temporal branch > orbit & forehead Zygomatic branch > zygomatic, orbital & intraorbital areas Buccal branch > buccinator & upper lip Mandibular branch > lower lip & chin Cervical branch > platysma Mastication ​ Stylohyoid and digastric posterior Stapedius Smallest skeletal muscle which moves the stapes in the inner ear If this is affected, the person’s hearing will be affected Sensory function Taste from anterior two thirds of tongue Assists in decreasing the intensity of sound from the tympanic membrane Autonomic function ​ Lacrimation ​ Sweating ​ Note If the lesion/compression occurs after the stylomastoid foramen (extracranial), only motor function will be affected VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Pathophysiology - Bell’s Palsy (Rattray/Ludwig; p811) One of the most common neurological conditions Affects 25 out of 100,000 each year Most common between ages 15 & 45 yrs Rapid onset of symptoms ​ From weakness to flaccidity very fast ​ Pain is very rare with Bell’s Palsy (and indicates an especially poor prognosis) A unilateral lesion of the facial nerve (CN VII) resulting in flaccid paralysis of the muscles of facial expression. ​ It may also affect autonomic (lacrimation, sweating) and sensory (taste) functions. It may also affect hearing because it innervates stapedius. Disruption to these fibres leads to hyperacusis - sounds are apparently very loud. Etiology Cause is not well understood Herpes simplex or zoster reactivation or other infection in inner ear Parotid gland infection (mumps) Trauma, esp. to temporal bone Tumors – acoustic neuroma, parotid gland There is an increased risk in those with diabetes mellitus & pregnant women in 3rd trimester Key sign ​ Eye closure difficult or impossible (orbicularis oculi) ​ Eye opening is fine because of different innervation (levator palpebrae superioris via cranial nerve 3) Manifestation (all unilateral) Forehead wrinkles disappear Overall droopy appearance Impossible or difficult to blink Nose runs & constantly stuffed Difficulty speaking, eating, drinking Sensitivity to low tones (hyperacusis) Excess or reduced salivation (autonomic) Facial swelling Pain in or near the ear Drooling Excessive or reduced tearing (autonomic) Brow droop Lower eyelid droop Sensitivity to light Loss taste anterior 2/3 of tongue VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy History Systemic disorders? ​ Diabetes, pregnancy, cardiovascular conditions Dr diagnosis (MD or neurologist)? ​ If so, what is the Dx? What is the prognosis? ​ What treatment are you receiving? Eye drops, eye patch, medication? Surgery? ​ Approved for local massage? Onset ​ Since when? Getting better, worse or the same? What is the rate of change? Sensory loss or change? ​ Taste, hearing? Changes to normal function? ​ Sweating, lacrimation, dry eyes? Pain? (not common) Assessment Observation ​ Drooping/downward pulling on affected side ​ Eye and mouth droop at corner on affected side ​ Inability to smile/make facial expressions on affected side ​ Loss of wrinkles on affected side Excess lacrimation AROM and RROM of muscles of facial expression: Raise eyebrows Bring eyebrows together Flare nostrils Smile showing teeth, not showing teeth Make an O shape with mouth Close the eyes Differential Stroke People often fear that paralysis on one side of the face is from a stroke (UMN). However, stroke generally affects the lower muscles of face (not frontalis mm or around eyes) VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy So, during a stroke, patient can close eye and wrinkle forehead but can't smile During Bell's Palsy, patient will be unable to close eye and wrinkle forehead Above and below on the left, we see a Bell’s Palsy; on the right, a stroke. VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Precaution Bell’s Palsy is a condition of nerve degeneration. Do not place prone Modify pressure for flaccid tissue Do not traction the nerve via dragging strokes on the affected side Always work towards the affected side to prevent dragging (bunch the tissue up starting from midline and working laterally on affected side) Place extra support (towel/pillow) around stylomastoid foramen on the affected side when person is supine Do not traction the supraclavicular area (platysma) away from the head as this will traction the nerve Do not use fascial techniques VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy Treatment Pre-treatment Position: Supine; have towel available for tearing and drooling Place towel between therapist and affected side to protect fragile tissue Hydro: Warm cloth on affected area for short period Cool washes on affected tissues (to stimulate, or for edema) Local heat over unaffected side to address TrP unless application will increase edema in affected tissues Treatment Always block to protect affected tissues Encourage diaphragmatic breathing Unaffected side ​ ​ Treat chest, post neck and shoulder, scalp, face ​ ​ Ensure pressure and stroking on unaffected side is toward lesion site (from lateral to midline) Affected Side: ​ ​ Techniques should move from mid-line toward the lesion ​ ​ No fascial techniques ​ Cue and assist with facial expressions: therapist aids with correct movement Light brushing/stroking towards lesion Home Care Hydro Apply cool cloth before exercise to stimulate the area Apply moderate moist heat for px relief Exercises Practice facial expressions in mirror: sniffle, wrinkle nose, flare nostrils, curl upper lip and protrude upper lip, compress lips together, pucker lips, smile w/ and w/o teeth 2-5 min at a time 2-3 times per day ADLs ​ MD for eye treatment ​ Use eye cover VCMT Peripheral Nervous System Treatments. Class 2 - Neuralgia (Intercostal & Trigeminal) & Bell’s Palsy