New facilitation exercise using the vestibulo-ocular reflex for ophthalmoplegia: preliminary report

Objective: To study the effect of facilitation exercises using the vestibulo-ocular reflex on ophthalmoplegia due to brainstem injury.

Design: A single-baseline design (A–B: A without specific therapy, B with specific therapy) across individual subjects.

Setting: Inpatient rehabilitation facility.

Subjects: Eight patients with ophthalmoplegia (total of 15 affected muscles) due to brainstem injury.

Interventions: Basic rehabilitative treatment that included physical therapy, occupational therapy and/or speech therapy for impairments such as hemiplegia, ataxia or dysarthria was administered for two weeks (control treatment). Then, two facilitation exercise sessions (100 times/day, five days/week for two weeks) were administered in addition to the basic rehabilitative treatment for four weeks to the eight patients with ophthalmoplegia. Ophthalmoplegia was evaluated at study entry and at the end of each two-week session. The goal of the facilitation exercises is to facilitate voluntary eye movement using conjugated eye movements in the direction opposite to passive movements of the head.

Main measures: To assess ophthalmoplegia we measured the distance between the internal/external corneal margin and the canthus of the affected eye on images recorded on a video tape recorder.

Results: After the initial two-week basic rehabilitative treatment, the distance between the corneal margin and canthus decreased slightly. Subsequently, after each of the two facilitation exercise sessions, there were significant reductions in the distance between the corneal margin and canthus compared with that at the beginning of the respective facilitation exercise session.

Conclusion: Facilitation exercises significantly improved the horizontal movement of eyes with ophthalmoplegia due to brainstem injury.

[Visual neurorehabilitation of patients with cerebral damage using botulinum toxin]

BACKGROUND

The neurorehabilitation of the patient with cerebral damage implies the reestablishment of the visual functions. Botulinum toxin can be considerate as a less invasive alternative for treatment.

OBJECTIVE

to demonstrate the answer to the treatment using botulinum toxin of the visual motor alterations in patients with cerebral damage.

METHODS

Descriptive study of patients with visual alterations associated to cerebral damage. The visual treatment included three areas: sensorial, refracting and motor under quimiodenervation with botulinum toxin, of May 2009 to May 2010.

RESULTS

48 patients were studied, age 22,4 years ± 23. The strabismus were: esotropia 52%, exotropia 39,5%, vertical 8%, nystagmus 4%. 50% of the patients had psychomotor delay. Some of the most important causes of cerebral damage were: Down syndrome, epilepsy, tumor, hydrocephalus, neuroinfection, infantile cerebral paralysis, multiple sclerosis, metabolic syndrome, cranial trauma, congenital cardiopathy, ventricular hemorrhage, cerebrovascular stroke. The dose of botulinum toxin was 8,1 UI ± 3. We registered good results in 56.5%, regular 23,9% and bad 19,5%. The global percentage of rehabilitation was 69% of correction with a r of Pearson of 0,5.

DISCUSSION

Patients with cerebral damage have diverse types of visuomotor alterations, strabismus and nystagmus.Use of botulinum toxin as a paralytic muscle agent is a good alternative in these cases.

CONCLUSION

The botulinum toxin is an effective option for the visual rehabilitation in patients with cerebral damage and prevents the progression of more cerebral changes secondary to strabismus.

[Acquired oculomotor paralysis: a new therapeutic approach. Apropos of 10 cases]

PURPOSE

The aim of this work is to report our rehabilitation scheme and outcome in patients with acquired oculomotor palsy.

PATIENTS AND METHODS

We cared for 10 patients with oculomotor palsy between January 1996 and March 1998 at the Casablanca University Hospital. Our orthoptic rehabilitation scheme was based on reinforcing the patient's sensorial potential using a prism dioper and motor capacities by soliciting vergency and version movements.

RESULTS

The 10 patients (7 males, 3 females, mean age 39.5 years) had unilateral IV palsy (n =3), bilateral IV palsy (n= 1), unilateral VI palsy (n= 2), bilateral VI palsy (n= 1), partial unilateral III palsy (n= 1) and dissociated bilateral III palsy (n= 2). Mean delay to initiation of rehabilitation was 49 days and mean duration for treatment was 3 months. We achieved total recovery in 50% of the cases and partial recovery in 40%. Intermittent diplopia persisted in 10 per thousand of the cases. These results differ slightly from those in the literature where total regression is reported in about 50% of the patients after therapeutic abstention.

CONCLUSION

This small series is insufficient to validate our method. The results obtained do however show that rehabilitation is safe and should be applied more widely in patients with oculomotor palsy.

Convergence insufficiency in brain-injured patients

Disorders of eye movements are relatively common in brain-injured patients. Some of these disturbances are caused by direct trauma to the orbital content, cranial nerves and other brain areas. Convergence, which is a part of the near-vision complex and depends on the integrative function of the cortical and subcortical areas, is commonly affected by traumatic brain injury. Intact vergence needs the integrative function of brain structures associated with acquisition of information on one side and intact mesencephalic function, including function of a vergence integrator, and their interconnections. Clinical investigation of vergence function in 26 traumatically brain-injured patients examined as early as possible after trauma revealed disturbances in over a third of the examinees. A follow-up of 72 patients some 3 years after injury revealed vergence insufficiency in 42%. Convergence insufficiency was associated with longer periods of coma (p less than 0.001), presence of cognitive disturbances (p less than 0.005) and patients' failing to find work in the open market (p less than 0.01). It is suggested that the presence of disturbed vergence several years after trauma, and its close association with prolonged coma and cognitive disturbances, is an expression of permanent damage to mesencephalic and cortical brain structures and can serve as an important aid in evaluation of these patients. This paper describes the close relationship between vergence state and over-all rehabilitation outcome as evaluated by patients' occupational status.

Rehabilitation in progressive supranuclear palsy: case report

Progressive supranuclear palsy (PSP) is a distinct clinicopathologic entity characterized by supranuclear ophthalmoplegia, pseudobulbar palsy, axial dystonia in extension, and subcortical dementia. Although relatively rare, PSP is disabling, thus rehabilitation techniques and management are indicated in nearly every case. This report describes the neurologic presentation, rehabilitation management, and outcome of treatment of a patient with PSP during a 12-month period. The patient required thorough neuromuscular, neuropsychological, speech, swallowing, vision, and social service evaluations prior to the implementation of a rehabilitation program. Therapeutic rehabilitation techniques focused on limb coordination activities, tilt board balancing, ambulation activities, and activities to improve route finding and visual scanning ability. Prism lenses were introduced to compensate for deficits in vertical eye movements. Treatment improved the patient's functional status. Later, as the patient's neurologic status deteriorated, it became necessary to educate the family and caretakers in the ongoing rehabilitation management of the patient.

Defective response to social cues in Möbius' syndrome

A case of Möbius' syndrome is presented, with the mask-like facies and poor social relationships consistent with this diagnosis. Previous thought has implicated the inability to transmit facial cues as a cause for impoverished social functioning. The authors hypothesize that the inability to transmit is related to an inability to receive cues. They repeated a paradigm used previously to test ability to interpret facial cues. The otherwise intelligent patient could not perform a task previously performed by approximately 300 other subjects. These findings suggest that the rehabilitation of Möbius patients should include education in interpreting social cues.

Vestibular stimulation for supranuclear gaze palsy: case report

Gaze palsies following severe destruction or irritative lesions of the cerebral hemispheres are rare. This report describes a patient with supranuclear ophthalmoplegia secondary to stroke which was rapidly resolved by cold caloric vestibular stimulation. The patient had a severe infarction of the right cerebral hemisphere and had a fixed deviated gaze to the right 3 months after onset. Cold caloric vestibular stimulation was used in an attempt to evaluate brain stem integrity. Following three successive injections of cold water at OC-5C into the external auditory canal, the patient regained full voluntary extraocular eye movements. The improvement continued for more than 12 months after the last treatment. A literature review of the neuroanatomy and neurophysiology of voluntary and reflex ocular movements is presented. A possible explanation for the improvement in this case is that vestibular input inhibits the tonic phase of antagonistic extraocular muscles while facilitating agonistic extraocular muscles.

Cryptogenic unilateral paralysis of the superior oblique muscle

Fifteen patients spontaneously developed paralysis of one superior oblique muscle, which remained unexplained after an initial evaluation. Follow-up evaluation showed that all of the patients' conditions were improved. Twelve of the patients had enjoyed spontaneous, functional recoveries within four months. Three had residual diplopia that was relieved by prisms. No patient subsequently developed evidence of any local or systemic disease that could explain the ophthalmoplegia. One patient suffered a recurrence 3 1/2 years after his first episode that lasted three months and spontaneously cleared.