Painful Tonic Spasms Research Articles

Hepatic Myelopathy with Painful Tonic Spasm: A Case Report

Hepatic myelopathy (HM) is a rare neurological complication of chronic liver disease, causing progressive spastic paraplegia or quadriplegia in the extremities with minimal sensory or sphincter impairment. In this article, the authors present one additional case with HM, with an exceptional clinical picture of painful tonic spasms within both thighs as the main complaint. A reduction in pain coinciding with a reduction in spasticity from treatments such as baclofen suggests a causal relationship between the two. We stress the importance of early recognizing this symptom before the spinal cord damage becomes irreversible.

Choreoathetosis in a patient with neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is a multifocal central nervous system demyelinating disease, and is associated with NMO-immunoglobulin G or anti-astrocyte water channel aquaporin-4 antibody. We report a 74-year-old woman with NMOSD who presented choreoathetosis. She developed left upper limb weakness and sensory impairment below the left C2 level, and the lesion was located primarily in the gray matter from the lower brainstem to the C6 level. Her symptoms were ameliorated after steroid pulse therapy, but painful tonic spasms (PTS) occurred in the affected limb. After gabapentin (600 mg/day) was started for the PTS, choreoathetotic movement appeared in her left upper limb. We suggest that modification of the gamma aminobutyric acid receptor activity and the cervical gray matter lesion had a role in the development of choreoathetosis.

Multiple sclerosis and pain

Despite the common belief that multiple sclerosis (MS) is a painless disease, several studies contradict this. There are a significant number of MS patients who actually suffer from painful conditions such as central and peripheral neuropathy, migraines, trigeminal neuralgia, painful tonic spasms, complex regional pain syndrome, glossopharyngeal neuralgia, and transverse myelitis. In addition, MS relapses are usually painful with many patients complaining of paroxysmal dystonia and neuropathic pain during these episodes. Additionally, treatments for MS such as use of beta-interferons may be associated with headache and pain at the injection site. The pathophysiology of pain in MS is poorly understood, but may be related to the development of demyelinating lesions involving certain neuroanatomic pathways such as the spinothalamic tract. Management of pain in MS patients is a therapeutic challenge for clinicians. Currently, various pharmacological agents such as antiepielptics, non-steroidal anti-inflammatory agents, and even corticosteroids are used to suppress various painful conditions associated with MS. Non-pharmacological procedures such as massage therapy have also been used in the treatment of MS patients. The authors present a review of recent findings in pathophysiology and management of pain in MS patients.

A mechanism-based classification of pain in multiple sclerosis

Pharmacological treatment of pain in multiple sclerosis (MS) is challenging due to the many underlying pathophysiological mechanisms. Few controlled trials show adequate pain control in this population. Emerging evidence suggests that pain might be more effectively classified and treated according to symptoms and underlying mechanisms. The new mechanism-based classification we propose here distinguishes nine types of MS-related pain: trigeminal neuralgia and Lhermitte’s phenomenon (paroxysmal neuropathic pain due to ectopic impulse generation along primary afferents), ongoing extremity pain (deafferentation pain secondary to lesion in the spino-thalamo-cortical pathways), painful tonic spasms and spasticity pain (mixed pains secondary to lesions in the central motor pathways but mediated by muscle nociceptors), pain associated with optic neuritis (nerve trunk pain originating from nervi nervorum), musculoskeletal pains (nociceptive pain arising from postural abnormalities secondary to motor disorders), migraine (nociceptive pain favored by predisposing factors or secondary to midbrain lesions), and treatment-induced pains. Identification of various types of MS-related pain will allow appropriate targeted pharmacological treatment and improve clinical practice.

Pain in Neuromyelitis Optica Is More Common, Disabling, and Refractory Compared to MS (P07.070)

Objective: Determine whether pain frequency, use of pain-relief medications, and pain level control differed between subjects with NMO versus MS. Background Pain is a frequent and disabling symptom among demyelinating diseases. Neuromyelitis optica (NMO) is associated with severe inflammatory lesions of the spinal cord and optic nerve, with potential for chronic pain. Design/Methods: Cross-sectional study (NMO=29, MS=66) included McGill Pain Score (MPS), Short Form 36 Scale (SF36), Center for Epidemiologic Studies Depression Scale (CES-D), Expanded Disability Status Score (EDSS), Multiple Sclerosis Functional Composite (MSFC). Involved T2 spinal segments were counted. CNS pain medications use was quantified. Results: Current pain was noted in 86% in NMO subjects, compared to 41% in MS. Severe current pain was present in 52% with NMO vs. 11% with MS. Painful tonic spasms were present in 90% with NMO vs. 39% with MS. McGill Pain Score had a positive correlation with involved spinal cord segments for NMO (r=0.45, p=0.02). Current pain on a 10 point scale was correlated with the physical component of the SF36 (r= -0.49, p Conclusions: Pain is very common in NMO, and is severe in the majority. Pain magnitude has a deleterious effect on quality of life. Although medications are often used to help relieve pain, many patients continue to suffer. Our pain medications may be contributing to side effects such as slowed cognition and fatigue. Supported by: NIH funding T32NS007205 to PQ. NIH funding K23NS052430 to RTN. Disclosure: Dr. Qian has received personal compensation for activities with Teva Neuroscience as an employee. Dr. Cross has received personal compensation for activities with Bayer Healthcare, Biogen Idec, Teva Neuroscience, Eli Lilly & Company, Hoffman-La Roche, and Genentech, Inc. Dr. Naismith has received personal compensation for activities with Acorda Therapeutics, Bayer Pharmaceuticals Corporation, and Biogen Idec as a consultant and/or speaker. Dr. Naismith has received personal compensation in an editorial capacity for Journal Watch Neurology. Dr. Naismith has received research from Acorda Therapeutics.

Pharyngeal Painful Tonic Spasms: Paroxysmal Painful Swallowing

Pharyngeal Painful Tonic Spasms: Paroxysmal Painful Swallowing

A Case Of Devic's Syndrome Presenting With Tonic Spasm: Response To Levetirasetam Treatment

Neuromyelitis optica or Devic's syndrome is a rare autoimmune disorder which is characterized by inflammatory demyelination of the optic nerves and the spinal cord. Clinically, it causes visual loss in one or both eyes, and numbness or paralysis of the arms and legs. Although tonic spasm is the most frequent movement disorder occuring in MS, it has not been definetely described clinical entity for Devic's syndrome. We hereby describe a case of Devic's syndrome with tonic spasms treated with levetiracetam as a new approach and discussed the results of the treatment. A 52-year-old woman with Devic's syndrome with the complaint of painful tonic spasms primarily affecting the abdomen was given levetiracetam therapy. Levetiracetam therapy resulted in a good response in our patient. Levetiracetam can be a new choice for the treatment of painful tonic spasm with Devic's syndrome. However, more detailed studies are necessary to investigate efficacy of levetiracetam.

The Jaundiced Newborn in the Emergency Department: Prevention of Kernicterus

A jaundiced neonate in an emergency department can be a catastrophic emergency that necessitates expeditious care. Progressive and irreversible bilirubin neurotoxicity may be minimized by rapid reduction of serum bilirubin concentrations through a “crash-cart” approach: immediate administration of intensive phototherapy and preparation for a possible exchange transfusion. Onset of acute bilirubin encephalopathy (ABE) is initially nonspecific and insidious and may progress to irritability, painful tonic spasms, apnea, seizures, obtundation, coma, respiratory failure, and death. Early recognition of hyperbilirubinemia severity can facilitate rapid transition to treatment and overcome the major barriers to timely therapy. Emergency department personnel need to develop policies that define access to intensive phototherapy either on site or immediate access to a neonatal/pediatric critical care facility. This article reviews a systems strategy for a crash-cart approach that may be initiated in the emergency department for a safer transition to alternative facilities to manage and prevent ABE.

Current Management of Pain Associated with Multiple Sclerosis

While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.

Pain associated with multiple sclerosis: Systematic review and proposed classification

Pain is common in patients with multiple sclerosis (MS), but estimates of its prevalence have varied widely. The literature describing pain in MS patients spans four decades and has employed a range of different methodologies. We undertook a systematic review in order to summarize current understanding of the association between MS and pain and provide a basis for the design and interpretation of future studies. The point prevalence of pain in patients with MS is nearly 50%, and approximately 75% of patients report having had pain within one month of assessment. Pain adversely affects most aspects of health-related quality of life, including functional domains such as the ability to work. The presence of pain in patients with MS is associated with increased age, duration of illness, depression, degree of functional impairment, and fatigue. Several different types of pain are found in patients with MS, including extremity pain, trigeminal neuralgia, Lhermitte’s sign, painful tonic spasms, back pain, and headache. Putative mechanisms of pain in patients with MS are discussed, and a classification of pain in MS is proposed. Few randomized clinical trials of treatments for MS pain have been conducted, and the limitations of current knowledge regarding approaches for treating MS pain are discussed. Suggestions for future studies that would increase understanding of the natural history, mechanisms, and treatment of pain in patients with MS are presented.

Thymectomy for paraneoplastic stiff-person syndrome associated with invasive thymoma

Stiff-person syndrome (SPS) is a rare autoimmune neurologic disorder characterized by painful tonic spasms in systemic skeletal muscles. 1 Anti-glutaminic acid decarboxylase (GAD) antibodies are produced with disturbing synthesis of -aminobutylic acid, one of the important suppressive neurotransmitters in the central nervous system. In some patients SPS is reportedly accompanied by thymomas, 2-4 and in these patients surgical resection of the malignancy reportedly reduces the neurologic symptoms of SPS. We report herein the clinical course of a patient with SPS associated with invasive thymoma.

Therapie von Schmerzen bei MS - eine Übersicht mit evidenzbasierten Therapieempfehlungen

While pain is a common problem in multiple sclerosis (MS) patients, it is frequently overlooked and has to be asked for actively. Pain can be classified into 4 diagnostically and therapeutically relevant categories. 1. PAIN DIRECTLY RELATED TO MS: Painful paroxysmal symptoms like trigeminal neuralgia or painful tonic spasms are treated with carbamazepine as first choice, or lamotrigine, gabapentin, oxcarbazepine and other anticonvulsants. Painful "burning" dysaesthesia, the most frequent chronic pain syndrome, are treated with tricyclic antidepressants or carbamazepine, further options include gabapentin or lamotrigine. While escalation therapy may require opioids, the role of cannabinoids in the treatment of pain still has to be determined. 2. PAIN INDIRECTLY RELATED TO MS: Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents like baclofen or tizanidine, alternatively gabapentin. In severe cases botulinum toxin injections or intrathecal baclofen merit consideration. Physiotherapy and physical therapy may ameliorate malposition-induced joint and muscle pain. Moreover, painful pressure lesions should be avoided using optimally adjusted aids. 3. Treatment-related pain can occur with subcutaneous injections of beta interferons or glatiramer acetate and may be reduced by optimizing the injection technique and by local cooling. Systemic side effects of interferons like myalgias can be reduced by paracetamol or ibuprofen. 4. Pain unrelated to MS such as back pain or headache are frequent in MS patients and may be worsened by the disease. Treatment should be follow established guidelines. In summary, a careful analysis of the pain syndrome will allow the design of the appropriate treatment plan using various medical and non-medical options and thus will help to ameliorate the patients' quality of life.

The prevalence of pain in multiple sclerosis: a multicenter cross-sectional study.

In a multicenter cross-sectional study, the authors assessed pain in patients with multiple sclerosis (MS) using a symptom-oriented approach. Out of 2,077 questionnaires, we used 1,672 for data analysis. Pain and frequencies included trigeminal neuralgia 2%, Lhermitte's sign 9%, dysesthetic pain 18.1%, back pain 16.4%, and painful tonic spasms 11%. Comparison between different groups showed significant differences for age, Expanded Disability Status Scale, disease duration, and disease course, but not for sex. This study underlines the relevance of pain in the clinical history of MS.

Botulinum toxin treatment of painful tonic spasms in multiple sclerosis.

Painful tonic spasms (PTS) involving upper or lower limbs can occur in patients with multiple sclerosis (MS). They may be disabling and difficult to manage.1-3⇓⇓ PTS have been attributed to ephaptic spreading of abnormal transient electric discharges throughout demyelinated axons, in the spinal cord, brainstem, or hemispheric white matter.4,5⇓ PTS are usually treated with antiepileptic medications such as carbamazepine, phenytoin, gabapentin, or benzodiazepines.1-3⇓⇓ These drugs, which require daily administration, may not provide adequate relief or may cause adverse effects.1 Because botulinum neurotoxin type A (BoNT/A) has proven effective in the treatment of hypertonic muscular activity of varying etiologies,6,7⇓ we tested it on patients with MS and PTS. We treated five patients with MS (three men, two women; age range 25 to 52 years), including three with a relapsing-remitting and two with a secondary progressive form. Clinical data are reported in table 1A. View this table: Table 1A. Clinical data of the five patients with multiple sclerosis …

Pain Management in Patients with Multiple Sclerosis

Although the idea that pain is not a symptom of multiple sclerosis (MS) continues, many studies have confirmed that over half of MS patients complain of pain. In some patients, it may be in part a result of the exacerbation of the disease. In other patients, it is an acute pain problem such as trigeminal neuralgia, bladder spasms, acute dysesthesia, Lhermitte′s phenomenon or painful tonic spasms. In even more cases, it is chronic pain that can take the form of dysesthesia, or repeated muscle spasms and aching. Although MS can cause pain, increasing disability can also produce other complications that are painful such as pressure palsies, decubiti, the effects of poorly fitting wheelchairs, or the musculoskeletal pain that results from the effort to maintain head position and posture with weakened muscles. All of the problem that MS patients experience do not necessarily result from their MS. MS patients can develop all of the medical conditions and pain situations that afflict the rest of the population, and these are usually manageable when the correct diagnosis is made and the approach is focused. Overall, most of the conditions causing pain in MS can be prevented, eliminated or improved, and the remaining patients with chronic pain are managed with strategies that are useful in approaching chronic pain in other situations.

Lamotrigine adjunctive therapy in painful phenomena in MS: preliminary observations.

Several types of painful phenomena may occur in MS, including burning paresthesias, pain in the extremities (paroxysmal or constant), and painful tonic spasms (PTS). These are particularly disturbing and often difficult to treat. Lamotrigine (LTG), a new antiepileptic drug, has been found to be effective against the paroxysmal pain of trigeminal neuralgia.1,2 We performed an open add-on study to assess whether LTG could also improve burning paresthesias, pain, and PTS in MS patients who were not responding to maximum doses of drugs that are usually effective. The cohort included 21 patients (16 female, 5 male) treated at the MS Regional Center in Cagliari, Italy. All had definite MS according to the criteria of Poser et al.3 Twelve had relapsing-remitting MS, 7 secondary progressive, and 2 primary progressive. Fifteen patients reported pain or burning paresthesias in the extremities (paroxysmal in 9 and continuous in 6), and …

Gabapentin Is Effective in Treating Nocturnal Painful Tonic Spasms in MS

Gabapentin Is Effective in Treating Nocturnal Painful Tonic Spasms in MS

Anatomic correlates of painful tonic spasms in multiple sclerosis.

Painful tonic spasms (PTS) are now regarded as a typical symptom of multiple sclerosis but pathologic or radiologic findings rarely have been described. We report clinical and magnetic resonance imaging records of five original cases. In all of them, lesions likely responsible for unilateral PTS involved the motor pathway at the level of the posterior limb of the internal capsule or the cerebral peduncle on the opposite side. Closeness of motor fibers seems to be the most important underlying anatomic factor because it enables involvement of a higher proportion of axons by a single demyelinating lesion and radial spread of ephaptic activation. In turn, preservation of the underlying pyramidal-spinal tract could make it easier for the pathologic discharge to reach the peripheral effectors and generate PTS.

An open-label trial of gabapentin treatment of paroxysmal symptoms in multiple sclerosis patients.

We conducted an open-label trial of gabapentin (GBP) as therapy for paroxysmal symptoms (PS) in 21 MS patients, including trigeminal neuralgia (6 patients), painful tonic spasms (11), dysesthetic or paresthetic symptoms (3) and ocular ataxia (1). Complete resolution of symptoms or partial improvement was obtained, respectively, in 14 and 4 of 18 patients who ended the study. Sustained improvement with minor side effects was obtained at dosages ranging from 600 to 1200 mg/d. Our findings suggest that GBP may be effective for PS in MS and warrant a further study in a double-blind placebo-controlled trial.

Painful tonic spasms: an interesting phenomenon in cerebral ischemia

We report a case of bilateral cerebral ischemia with frequent painful tonic spasms involving face, both upper and sometimes both lower extremities. The spasms subsided after treatment with diazepam.