Made by DATEXIS (Data Science and Text-based Information Systems) at Beuth University of Applied Sciences Berlin
Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
Initial line of treatment is with anti-inflammatory drugs or cortisone injections. There have been trials with gloves which help protect the ulnar nerve from compression. The most radical treatment option is surgery to relieve tension in the volar carpal ligament which forms the roof of Guyon's canal, thereby reducing compression on the ulnar nerve.
The place of chiropractic-, physical-, occupational-, massage- and osteopathic therapy was not confirmed in scientific studies. These treatments can be both expensive as well as dangerous (causing permanent damage when performed wrongly).
It is advised to consult a physician beforehand starting any therapy, albeit an alternative approach, to avoid any permanent nerve damage.
While pain symptoms may be effectively controlled using medications such as NSAID, amitriptyline, or vitamin B6 supplementation, effective treatment generally requires resolving the underlying cause.
Mild to moderate symptoms, such as pain or paresthesia, are treated conservatively with non-surgical approaches. Physiotherapy treatments can prove effective at treating cubital tunnel syndrome symptoms and can include:
- Joint mobilizations
- Neural flossing/gliding
- Strengthening/stretching exercises
- Activity modification
It is important to identify positions and activities that aggravate symptoms and to find ways to avoid them. For example, if the person experiences symptoms when holding a telephone up to the head, then the use of a telephone headset will provide immediate symptomatic relief and reduce the likelihood of further damage and inflammation to the nerve. For cubital tunnel syndrome, it is recommended to avoid repetitive elbow flexion and also avoiding prolonged elbow flexion during sleep, as this position puts stress of the ulnar nerve.
Surgery is recommended for those who are not improved with conservative therapy or those with serious or progressive symptoms. The surgical approaches vary, and may depend on the location or cause of impingement. Cubital and ulnar tunnel release can be performed wide awake with no general anaesthesia, no regional anaesthesia, no sedation and no tourniquet, and are usually done by Plastic Surgeons
Cubital tunnel syndrome may be prevented or reduced by maintaining good posture and proper use of the elbow and arms, such as wearing an arm splint while sleeping to maintain the arm is in a straight position instead of keeping the elbow tightly bent. A recent example of this is popularization of the concept of cell phone elbow.
There are numerous pharmaceutical treatments for neuropathic pain associated with pudendal neuralgia. Drugs used include anti-epileptics (like gabapentin), antidepressants (like amitriptyline), and palmitoylethanolamide.
Alcock canal infiltration with corticosteroids is a minimally invasive technique which allows for pain relief and could be tried when physical therapy has failed and before surgery. A long-acting local anesthetic (bupivacaine hydrochloride) and a corticosteroid (e.g. methylprednisolone) are injected to provide immediate pudendal anesthesia. The injections may also bring a long-term response because the anti-inflammatory effects of the steroid and steroid-induced fat necrosis can reduce inflammation in the region around the nerve and decrease pressure on the nerve itself. This treatment may be effective in 65–73% of patients.
Physical therapy can be somewhat useful for patient’s recovery from surgery. The main focus of rehabilitation is centered on controlling the bladder and bowel functions and decreasing muscle weakness in the lower extremities.
Physiotherapy
To increase strength of muscle
To improve muscle functions
Electrical modalities =Electric stimulation.etc.
Occupational Therapy
Positioning, ROM, Sensory, Splinting
The management of true cauda equina syndrome frequently involves surgical decompression. When cauda equina syndrome is caused by a herniated disk early surgical decompression is recommended.
Cauda equina syndrome of sudden onset is regarded as a medical/surgical emergency. Surgical decompression by means of laminectomy or other approaches may be undertaken within 6, 24 or 48 hours of symptoms developing if a compressive lesion, e.g., ruptured disc, epidural abscess, tumour or haematoma is demonstrated. Early treatment may significantly improve the chance that long-term neurological damage will be avoided.
Surgery may be required to remove blood, bone fragments, a tumor or tumors, a herniated disc or an abnormal bone growth. If the tumor cannot be removed surgically and it is malignant then radiotherapy may be used as an alternative to relieve pressure, with spinal neoplasms chemotherapy can also be used. If the syndrome is due to an inflammatory condition e.g., ankylosing spondylitis, anti-inflammatory, including steroids can be used as an effective treatment. If a bacterial infection is the cause then an appropriate course of antibiotics can be used to treat it.
Cauda equina syndrome can occur during pregnancy due to lumbar disc herniation; age of mother increases the risk. Surgery can still be performed and the pregnancy does not adversely affect treatment. Treatment for those with cauda equina can and should be carried out at any time during pregnancy.
Lifestyle issues may need to be addressed post - treatment. Issues could include the patients need for physiotherapy and occupational therapy due to lower limb dysfunction. Obesity might also need to be tackled.
Ulnar tunnel syndrome, also known as Guyon's canal syndrome or Handlebar palsy, is caused by entrapment of the ulnar nerve in the Guyon canal as it passes through the wrist. Symptoms usually begin with a feeling of pins and needles in the ring and little fingers before progressing to a loss of sensation and/or impaired motor function of the intrinsic muscles of the hand which are innervated by the ulnar nerve. Ulnar tunnel syndrome is commonly seen in regular cyclists due to prolonged pressure of the Guyon's canal against bicycle handlebars. Another very common cause of sensory loss in the ring and pink finger is due to ulnar nerve entrapment at the Cubital Tunnel near the elbow, which is known as Cubital Tunnel Syndrome.
Blocking agents of the adrenoceptors alpha 1/alpha 2 are typically used to treat the effects of the vasoconstriction associated with vascular claudication. Cilostazol (trade name: Pletal) is FDA approved for intermittent claudication. It is contraindicated in patients with heart failure, and improvement of symptoms may not be evident for two to three weeks.
Neurogenic claudication can be treated surgically with spinal decompression.
Potential non-surgical treatments include:
- Education about the course of the condition and how to relieve symptoms
- Medicines to relieve pain and inflammation, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs)
- Exercise, to maintain or achieve overall good health, aerobic exercise, such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms
- Weight loss, to relieve symptoms and slow progression of the stenosis
- Physical therapy, to provide education, instruction, and support for self-care; physical therapy instructs on stretching and strength exercises that may lead to a decrease in pain and other symptoms
The evidence for the use of medical interventions for lumbar spinal stenosis is poor. Injectable but not nasal calcitonin may be useful for short term pain relief. Epidural blocks may also transiently decrease pain, but there is no evidence of long-term effect. Adding steroids to these injections does not improve the result; the use of epidural steroid injections (ESIs) is controversial and evidence of their efficacy is contradictory.
Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and opioid analgesics are often used to treat low back pain, but evidence of their efficacy is lacking.
Treatment options are either surgical or non-surgical. Overall evidence is inconclusive whether non-surgical or surgical treatment is the better for lumbar spinal stenosis.
The effectiveness of non surgical treatments is unclear as they have not been well studied.
- Education about the course of the condition and how to relieve symptoms
- Medicines to relieve pain and inflammation, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs)
- Exercise, to maintain or achieve overall good health, aerobic exercise, such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms
- Weight loss, to relieve symptoms and slow progression of the stenosis
- Physical therapy to support self-care. Also may give instructs on stretching and strength exercises that may lead to a decrease in pain and other symptoms.
- Lumbar epidural steroid or anesthetic injections have low quality evidence to support their use.
A trial of the anticonvulsant drug carbamazepine is common for patients diagnosed with GN. For patients who do not tolerate or respond to carbamazepine, alternative drugs include oxcarbazepine, gabapentin, phenytoin, lamotrigine, and baclofen. In addition, tricyclics (e.g., amitriptyline) and pregabalin are useful in other types of neuropathic pain.
Management of shoulder dystocia has become a focus point for many obstetrical nursing units in North America. Courses such as the Canadian More-OB program encourage nursing units to do routine drills to prevent delays in delivery which adversely affect both mother and fetus. A common treatment mnemonic is ALARMER
- Ask for help. This involves preparing for the help of an obstetrician, for anesthesia, and for pediatrics for subsequent resuscitation of the infant that may be needed if the methods below fail.
- L hyperflexion (McRoberts' maneuver)
- Anterior shoulder disimpaction (pressure)
- Rubin maneuver
- M delivery of posterior arm
- Episiotomy
- Roll over on all fours
Typically the procedures are performed in the order listed above and the sequence ends whenever a technique is successful. Intentional clavicular fracture is a final attempt at nonoperative vaginal delivery prior to Zavanelli's maneuver or symphysiotomy, both of which are considered extraordinary treatment measures.
Surgery appears to lead to better outcomes if there are ongoing symptoms after three to six months of conservative treatment. Laminectomy is the most effective of the surgical treatments. In those who worsen despite conservative treatments surgery leads to improvement in 60–70% of cases. Another procedure using an interspinous distraction device known as X-STOP was less effective and more expensive when more than one spinal level is repaired. Both surgical procedures are more expensive than medical management.
Sedative drugs are often prescribed for vertigo and dizziness, but these usually treat the symptoms rather than the underlying cause. Lorazepam (Ativan) is often used and is a sedative which has no effect on the disease process, but rather helps patients cope with the sensation.
Anti-nauseants, like those prescribed for motion sickness, are also often prescribed but do not affect the prognosis of the disorder.
Specifically for Meniere's disease a medication called Serc (Beta-histine) is available. There is some evidence to support its effectiveness in reducing the frequency of attacks. Also Diuretics, like Diazide (HCTZ/triamterene), are effective in many patients. Finally, ototoxic medications delivered either systemically or through the eardrum can eliminate the vertigo associated with Meniere's in many cases, although there is about a 10% risk of further hearing loss when using ototoxic medications.
Treatment is specific for underlying disorder of balance disorder:
- anticholinergics
- antihistamines
- benzodiazepines
- calcium channel antagonists, specifically Verapamil and Nimodipine
- GABA modulators, specifically gabapentin and baclofen
- Neurotransmitter reuptake inhibitors such as SSRIs, SNRIs and Tricyclics
Once diagnosed, the gap in the temporal bone can be repaired by surgical resurfacing of the affected bone or plugging of the superior semicircular canal. These techniques are performed by accessing the site of the dehiscence either via a middle fossa craniotomy or via a canal drilled through the transmastoid bone behind the affected ear. Bone cement has been the material most often used, in spite of its tendency to slippage and resorption, and a consequent high failure rate; recently, soft tissue grafts have been substituted.
Potential surgical treatments include:
- Anterior cervical discectomy and fusion - A surgical treatment of nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae.
- Laminoplasty - A surgical procedure relieve pressure on the spinal cord by cutting the lamina on both sides of the affected vertebrae (cutting through on one side and merely cutting a groove on the other) and then "swinging" the freed flap of bone open.
- Laminectomy - A surgical procedure in which the lamina of the vertebra is removed or trimmed to widen the spinal canal and create more space for the spinal nerves and thecal sac.
Dysequilibrium arising from bilateral loss of vestibular function – such as can occur from ototoxic drugs such as gentamicin – can also be treated with balance retraining exercises (vestibular rehabilitation) although the improvement is not likely to be full recovery.
Medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of BPPV, but in most cases are not indicated. These primarily include drugs of the anti-histamine and anti-cholinergic class, such as meclizine and hyoscine butylbromide (scopolamine) respectively. The medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications) have emerged for the treatment of vertigo/dizziness syndromes. These drugs vary considerably in their mechanisms of action, with many of them being receptor- or ion channel-specific. Among them are betahistine or dexamethasone/gentamicin for the treatment of Ménière's disease, carbamazepine/oxcarbazepine for the treatment of paroxysmal dysarthria and ataxia in multiple sclerosis, metoprolol/topiramate or valproic acid/tricyclic antidepressant for the treatment of vestibular migraine, and 4-aminopyridine for the treatment of episodic ataxia type 2 and both downbeat and upbeat nystagmus. These drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. Medications may be used to suppress symptoms during the positioning maneuvers if the patient's symptoms are severe and intolerable. More dose-specific studies are required, however, in order to determine the most effective drug(s) for both acute symptom relief and long-term remission of the condition.
Courses that teach procedures include ALSO and PROMPT. A number of labor positions and/or obstetrical maneuvers are sequentially performed in attempt to facilitate delivery at this point, including :
- McRoberts maneuver; The McRoberts maneuver is employed in case of shoulder dystocia during childbirth and involves hyperflexing the mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled. The technique is effective in about 42% of cases
- suprapubic pressure (or Rubin I)
- Rubin II or posterior pressure on the anterior shoulder, which would bring the fetus in an oblique position with head somewhat towards the vagina
- Woods' screw maneuver which leads to turning the anterior shoulder to the posterior and vice versa (somewhat the opposite of Rubin II maneuver)
- Jacquemier's maneuver (also called Barnum's maneuver), or delivery of the posterior shoulder first, in which the forearm and hand are identified in the birth canal, and gently pulled.
- Gaskin maneuver, named after Certified Professional Midwife, Ina May Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.
More drastic maneuvers include
- Zavanelli's maneuver, which involves pushing the fetal head back in with performing a cesarean section. or internal cephalic replacement followed by Cesarean section
- intentional fetal clavicular fracture, which reduces the diameter of the shoulder girdle that requires to pass through the birth canal.
- maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.
- abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates vaginal delivery of the impacted shoulder
EMG &NCV can help to treatment with the diagnosis of the location and severity of the lesion.
Treatment with the steroid "prednisone" and the antiviral drug "acyclovir 800mg 5 times a day" is controversial, with some studies showing to achieve complete recovery in patients if started within the first three days of facial paralysis, with chances of recovery decreasing as treatment was delayed. Delay of treatment may result in permanent facial nerve paralysis. However, some studies demonstrate that even when steroids are started promptly, only 22% of all patient achieve full recovery of facial paralysis.
Treatment apparently has no effect on the recovery of hearing loss. Diazepam is sometimes used to treat the vertigo.